Eighteen-Year Trends in the Prevalence of, and Health Care Use for, Noncancer Pain in the United States: Data from the Medical Expenditure Panel Survey

The Relation of Health Anxiety to Treatment Utilization Among Patients with Substance Use Disorders: The Moderating Role of Racial/Ethnic Background

Background: Although health anxiety is broadly related to the overutilization of healthcare, limited research has examined this relation among individuals with substance use disorders (SUDs), or the extent to which racial/ethnic differences influence this relationship. Objectives: The purpose of the current study is to examine the moderating role of racial/ethnic minoritized background in the relationship between health anxiety and treatment utilization among individuals with SUDs. In the present study, patients with SUDs receiving residential treatment in Mississippi (N=118; 62% racial/ethnic minoritized status, 35.6% White) completed a measure of health anxiety and answered questions about past mental health, physical health, and substance use treatment. Regression models examined whether racial/ethnic minoritized status (White vs. racial/ethnic minoritized status) moderated the relation of health anxiety to treatment utilization among patients with SUDs. Treatment utilization was examined by asking whether participants had seen a doctor or mental health provider, engaged in substance use treatment, or alcohol treatment prior to their current treatment (dichotomous), as well as the number of times they had engaged in each treatment (physical health, mental health, substance use, and alcohol treatment) in the past year (continuous). Results: Results revealed that the facets of health anxiety involving concerns about pain and disease phobia were positively associated with treatment utilization, but only among racial/ethnic minoritized participants, with concerns about pain positively associated with self-reported physical health treatment utilization (OR=0.70, 95% CI=0.50; 0.97) and disease phobia positively associated with past mental health (B = 0.36, p = 0.023) and alcohol use treatment (B=-0.23, p=.009). Conversely, disease phobia was related to less prior alcohol use treatment among White participants (B=-0.23, p=.009). Conclusions: Overall, among patients in residential treatment for SUDs, racial/ethnic minoritized participants with SUDs reported more health anxiety compared to white participants, and certain facets of health anxiety (i.e., concerns about pain and worry about severe illness) were linked to heightened treatment utilization among racial/ethnic minoritized individuals.

Nationally Representative Rates of Incident Prescription Opioid Use Among United States Adults and Selected Subpopulations: Longitudinal Cohort Study from the National Health Interview Survey, 2019-2020

Nationally representative rates of incident prescription opioid use in the United States (U.S.) adult population and selected subpopulations are unknown. Using the National Health Interview Survey (2019-2020) longitudinal cohort, a cohort with 1-year follow-up created using random cluster probability sampling of non-institutionalized civilian U.S. adults, we estimated rates and predictors of incident opioid use. Of 21,161 baseline (2019) participants randomly chosen for follow-up, the final analytic sample included 10,415 who also participated in 2020. Exposure variables were selected per the socio-behavioral model of healthcare utilization: predisposing characteristics (sex, age, race, etc.), enabling characteristics (socioeconomic status, insurance status), health status (pain, disability, comorbidities, etc.), and healthcare use (office visits, emergency room [ER] visits, hospitalizations). Among adults who did not use prescription opioids in 2019, a one-year cumulative incidence of 4.1% (95% CI:3.5-4.6) was seen in 2020, with an incidence rate (IR) of 32.6 cases of new prescription opioid use per 1,000 person-years (PY). Cumulative incidence, IR, and adjusted relative risk (RR) varied by participant characteristics. We observed the highest IR in those with ineffective pain treatment (81.6 cases per 1,000 PY) and those who visited the ER ≥3 times (93.8 cases per 1,000 PY). Participants reporting ≥4 painful conditions had an adjusted RR of 2.9 (95% CI:2.0-4.1), while the RR for those with sleep problems was 2.3 (95% CI:1.7-3.1). Overall, this study presents nationally representative rates of incident prescription opioid use, and suggests that some participants are using prescription opioids as an early resort analgesic contrary to best practice guidelines. PERSPECTIVE: This longitudinal cohort study presents nationally representative rates of incident prescription opioid use in U.S. adults and selected subpopulations. Our data suggest that some participants are using prescription opioids as a first-line or early resort analgesic, contrary to best practice guidelines.

Are We Adding Pain-Free Years to Life? A Test of Compression Versus Expansion of Morbidity

BACKGROUND

There has been debate regarding whether increases in longevity result in longer and healthier lives or more disease and suffering. To address the issue, this study uses health expectancy methods and tests an expansion versus compression of morbidity with respect to pain.

METHODS

Data are from 1993 to 2018 Health and Retirement Study. Pain is categorized as no pain, nonlimiting, and limiting pain. Multistate life tables examine 77 996 wave-to-wave transitions across pain states or death using the Stochastic Population Analysis for Complex Events program. Results are presented as expected absolute and relative years of life for 70-, 80-, and 90-year-old men and women. Confidence intervals assess significance of differences over time. Population- and status-based results are presented.

RESULTS

For those 70 and 80 years old, relative and absolute life with nonlimiting and limiting pain increased substantially for men and women, and despite variability on a wave-to-wave basis, results generally confirm an expanding pain morbidity trend. Results do not vary by baseline status, indicating those already in pain are just as likely to experience expansion of morbidity as those pain-free at baseline. Results are different for 90-year-olds who have not experienced expanding pain morbidity and do not show an increase in life expectancy.

CONCLUSIONS

Findings are consistent with extant literature indicating increasing pain prevalence among older Americans and portend a need for attention to pain-coping resources, therapies, and prevention strategies.

The geography of arthritis-attributable pain outcomes: a county-level spatial analysis

ABSTRACT

Research on the geographic distribution of pain and arthritis outcomes, especially at the county level, is limited. This is a high-priority topic, however, given the heterogeneity of subnational and substate regions and the importance of county-level governments in shaping population health. Our study provides the most fine-grained picture to date of the geography of pain in the United States. Combining 2011 Behavioral Risk Factor Surveillance System data with county-level data from the Census and other sources, we examined arthritis and arthritis-attributable joint pain, severe joint pain, and activity limitations in US counties. We used small area estimation to estimate county-level prevalences and spatial analyses to visualize and model these outcomes. Models considering spatial structures show superiority over nonspatial models. Counties with higher prevalences of arthritis and arthritis-related outcomes are mostly clustered in the Deep South and Appalachia, while severe consequences of arthritis are particularly common in counties in the Southwest, Pacific Northwest, Georgia, Florida, and Maine. Net of arthritis, county-level percentages of racial/ethnic minority groups are negatively associated with joint pain prevalence, but positively associated with severe joint pain prevalence. Severe joint pain is also more common in counties with more female individuals, separated or divorced residents, more high school noncompleters, fewer chiropractors, and higher opioid prescribing rates. Activity limitations are more common in counties with higher percentages of uninsured people. Our findings show that different spatial processes shape the distribution of different arthritis-related pain outcomes, which may inform local policies and programs to reduce the risk of arthritis and its consequences.

Intersectional Risk and the Significant Gap in Care for Persons With Co-occurring Chronic Pain and Opioid Withdrawal

OBJECTIVES

Persons with chronic pain and women tend to enter treatment for opioid use disorder with greater opioid withdrawal severity than persons without chronic pain and men, respectively. This study examined characteristics of facilities with opioid withdrawal treatment, including gender-based services, as a function of whether they reported having a tailored pain management program.

METHODS

The National Survey of Substance Abuse Treatment Services 2020 was used to examine 3942 facilities with opioid withdrawal treatment in the United States. Using a multivariable binary logistic regression model, facilities were examined for the presence of a tailored program for individuals with co-occurring pain. Regional location of the facility, ownership status, and availability of tailored gender programs, nonhospital residential services, and outpatient services served as independent variables in the analysis.

RESULTS

A slight majority of the sample had a program for both adult men and adult women ( n = 2010, 51.0%). Most facilities had outpatient services ( n = 3289, 83.4%) and did not have a tailored program for addressing co-occurring pain ( n = 2756, 69.9%). Binary logistic regression analysis showed that among opioid withdrawal facilities, programs with nonhospital residential services, government or private nonprofit funding, or tailored gender programming had higher odds of reporting having a tailored program for pain and substance use disorder. Facilities in the Western United States were most likely to have tailored programs for pain and substance use disorder.

CONCLUSIONS

Future research should investigate what support patients may receive and how to better scale access to pain management during opioid withdrawal treatment.

Seventeen-Year National Pain Prevalence Trends Among U.S. Military Veterans

U.S. military veterans experience higher pain prevalence than nonveterans. However, it is unclear how the disparities in pain prevalence have changed over time because previous trend studies are limited to veterans using the Veterans Health Administration. This repeated cross-sectional study aimed to characterize pain prevalence trends in the overall population of U.S. veterans compared to nonveterans, using nationally representative data. We analyzed 17 years of data from the National Health Interview Survey (2002-2018), with a mean annual unweighted sample of 29,802 U.S. adults (total unweighted n = 506,639) and mean annual weighted population of 229.7 million noninstitutionalized adults. The weighted proportion of veterans ranged from 11.48% in 2002 (highest) to 8.41% in 2017 (lowest). We found that veterans experience a similar or higher prevalence of pain than nonveterans across the study period, except for severe headaches or migraine and facial pain. Pain prevalence among veterans increased over time, with a higher rate of increase compared to nonveterans for all pain variables. From 2002 to 2018, there was an absolute increase (95% confidence interval) in pain prevalence among veterans (severe headache or migraine: 2.0% [1.6-2.4%]; facial pain: 1.9% [1.4-2.4%]; neck pain: 4.7% [4.1-5.2%]; joint pain: 11.4% [10.8-11.9%]; low back pain: 10.3% [9.5-11.1%]; any pain: 10.0% [9.6-10.4%]; and multiple pains: 9.9% [9.2-10.6%]). The continued pain prevalence increase among veterans may have implications for health care utilization, highlighting the need for improved pain prevention and care programs for this population with a disproportionate pain burden. PERSPECTIVE: This article uses routinely-collected cross-sectional data that are nationally representative of U.S. adults to present changes in pain prevalence among military veterans compared to nonveterans. The findings underscore the need for improved prevention and pain care programs for veterans, who experienced a widening disproportionate pain burden from 2002 to 2018.

Examining the prevalence of sleep disturbances in patients seeking physical therapy services

OBJECTIVE

The purpose of this study was to assess the prevalence of sleep disturbances in adults seeking physical therapy services.

METHODS

Participants were issued an electronic survey to provide demographic information and the following questionnaires: Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Sleep Hygiene Index (SHI), Insomnia Severity Index (ISI), STOP-BANG (obstructive sleep apnea (OSA) risk), and restless leg syndrome (RLS) risk. Percentages were calculated to describe prevalence of sleep disturbances, and Spearman's correlations were used to identify associations between pain and sleep questionnaires.

RESULTS

Eighty-eight participants (47.9 ± 15.8 years, 68 females) completed the survey. Seventy-eight percent (n = 69) scored >5 on the PSQI; 32% (n = 28) scored ≥10 on the ESS; 52% (n = 46) scored ≥16 on the SHI; 51% (n = 45) scored ≥10 on the ISI; 28% (n = 25) had intermediate or high risk of OSA; and 40% (n = 35) indicated possible RLS. Pain level was significantly associated with PSQI (r(86) = 0.277, p = .009) and ISI (r(86) = 0.268, p = .012).

CONCLUSIONS

There was a higher prevalence of sleep disturbances in adults seeking physical therapy services than in the general population. Increased pain severity was associated with poorer sleep quality and increased insomnia symptoms. This study highlights the need to screen patients for sleep disturbances.

Reevaluating the "deaths of despair" narrative: Racial/ethnic heterogeneity in the trend of psychological distress-related death

Despite the significant scientific advancement in deciphering the "deaths of despair" narrative, most relevant studies have focused on drug-, alcohol-, and suicide-related (DAS) deaths. This study directly investigated despair as a determinant of death and the temporal variation and racial heterogeneity among individuals. We used psychological distress (PD) as a proxy for despair and drew data from the US National Health Interview Survey-Linked Mortality Files 1997 to 2014, CDC (Centers for Disease Control and Prevention) Multiple Cause of Death database 1997 to 2014, CDC bridged-race population files 1997 to 2014, Current Population Survey 1997 to 1999, and the American Community Survey 2000 to 2014. We used Cox proportional hazards models to estimate mortality hazard ratios of PD and compared age-standardized PD- and DAS-related mortality rates by race/ethnicity and over time. We found that while Whites had a lower prevalence of PD than Blacks and Hispanics throughout the whole period, they underwent distinctive increases in PD-related death and have had a higher PD-related mortality rate than Blacks and Hispanics since the early 2000s. This was predominantly due to Whites' relatively high and increasing vulnerability to PD less the prevalence of PD. Furthermore, PD induced a more pervasive mortality consequence than DAS combined for Whites and Blacks. In addition, PD- and DAS-related deaths displayed a concordant trend among Whites but divergent patterns for Blacks and Hispanics. These findings suggest that 1) DAS-related deaths underestimated the mortality consequence of despair for Whites and Blacks but overestimated it for Hispanics; and 2) despair partially contributed to the DAS trend among Whites but probably not for Blacks and Hispanics.

Use of Complementary Health Approaches Overall and for Pain Management by US Adults

This study examines prevalence of use of complementary health approaches overall and for pain management among US adults.

The Association Between Racialized Discrimination in Health Care and Pain Among Black Patients With Mental Health Diagnoses

Chronic pain is a costly and debilitating problem in the United States, and its burdens are exacerbated among socially disadvantaged and stigmatized groups. In a cross-sectional study of Black Veterans with chronic pain at the Atlanta VA Health Care System (N = 380), we used path analysis to explore the roles of racialized discrimination in health care settings, pain self-efficacy, and pain-related fear avoidance beliefs as potential mediators of pain outcomes among Black Veterans with and without an electronic health record-documented mental health diagnosis. In unadjusted bivariate analyses, Black Veterans with a mental health diagnosis (n = 175) reported marginally higher levels of pain-related disability and significantly higher levels of pain interference compared to those without a mental health diagnosis (n = 205). Path analyses revealed that pain-related disability, pain intensity, and pain interference were mediated by higher levels of racialized discrimination in health care and lower pain self-efficacy among Black Veterans with a mental health diagnosis. Pain-related fear avoidance beliefs did not mediate pain outcomes. These findings highlight the need to improve the quality and effectiveness of health care for Black patients with chronic pain through the implementation of antiracism interventions within health care systems. Results further suggest that Black patients with chronic pain who have a mental health diagnosis may benefit from targeted pain management strategies that focus on building self-efficacy for managing pain. PERSPECTIVE: Racialized health care discrimination and pain self-efficacy mediated differences in pain-related disability, pain intensity, and pain interference among Black Veterans with and without a mental health diagnosis. Findings highlight the need for antiracism interventions within health care systems in order to improve the quality of care for Black patients with chronic pain. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01983228.

Global pain levels before and during the COVID-19 pandemic

Physical pain has trended upward globally over the last decade. Here, we explore whether the COVID-19 pandemic modified this alarming trend. We used data from 146 countries worldwide (510,247 respondents) to examine whether pain levels changed during the COVID-19 pandemic. Adjusted regressions across countries revealed that 33.3% of people were in pain in 2019, 32.8% in 2020, 32.5% in 2021, and 34.1% in 2022. The change in pain from 2019 to each of the pandemic years was not statistically significant. This suggests that, on average, there was no significant change in pain during the pandemic. However, from 2019 to 2020 there was a significant decline in pain among individuals over 55 years of age, those who were widowed, and those without children in the household. On a global scale, the COVID-19 pandemic was not associated with a significant change in pain levels. The concerning pre-pandemic elevation in global pain continued during this challenging period.

Food insecurity is associated with chronic pain and high-impact chronic pain in the USA

OBJECTIVE

This study evaluated whether food insecurity (US Adult Food Security Survey) was associated with chronic pain (≥ 3 months) and high-impact chronic pain (i.e. pain that limits work and life) among US adults.

DESIGN

Cross-sectional analysis.

SETTING

Nationally representative sample of non-institutionalised adults in the USA.

PARTICIPANTS

79 686 adults from the National Health Interview Survey (2019-2021).

RESULTS

Marginal, low and very low food security were associated with increased prevalence odds of chronic pain (OR: 1·58 (95 % CI 1·44, 1·72), 2·28 (95 % CI 2·06, 2·52) and 3·37 (95 % CI 3·01, 3·78), respectively) and high-impact chronic pain (OR: 1·28 (95 % CI 1·14, 1·42), 1·55 (95 % CI 1·37, 1·75) and 1·90 (95 % CI 1·65, 2·18), respectively) in a dose-response fashion (P-trend < 0·0001 for both), adjusted for sociodemographic, socio-economic and clinically relevant factors. Participation in Supplemental Nutrition Assistance Program (SNAP) and age modified the association between food insecurity and chronic pain.

CONCLUSIONS

These findings illustrate the impact of socio-economic factors on chronic pain and suggest that food insecurity may be a social determinant of chronic pain. Further research is needed to better understand the complex relationship between food insecurity and chronic pain and to identify targets for interventions. Moreover, the consideration of food insecurity in the clinical assessment of pain and pain-related conditions among socio-economically disadvantaged adults may be warranted.

Evaluating chronic pain as a risk factor for COVID-19 complications among New York State Medicaid beneficiaries: a retrospective claims analysis

OBJECTIVE

To assess whether chronic pain increases the risk of COVID-19 complications and whether opioid use disorder (OUD) differentiates this risk among New York State Medicaid beneficiaries.

DESIGN, SETTING, AND SUBJECTS

This was a retrospective cohort study of New York State Medicaid claims data. We evaluated Medicaid claims from March 2019 through December 2020 to determine whether chronic pain increased the risk of COVID-19 emergency department (ED) visits, hospitalizations, and complications and whether this relationship differed by OUD status. We included beneficiaries 18-64 years of age with 10 months of prior enrollment. Patients with chronic pain were propensity score-matched to those without chronic pain on demographics, utilization, and comorbidities to control for confounders and were stratified by OUD. Complementary log-log regressions estimated hazard ratios (HRs) of COVID-19 ED visits and hospitalizations; logistic regressions estimated odds ratios (ORs) of hospital complications and readmissions within 0-30, 31-60, and 61-90 days.

RESULTS

Among 773 880 adults, chronic pain was associated with greater hazards of COVID-related ED visits (HR = 1.22 [95% CI: 1.16-1.29]) and hospitalizations (HR = 1.19 [95% CI: 1.12-1.27]). Patients with chronic pain and OUD had even greater hazards of hospitalization (HR = 1.25 [95% CI: 1.07-1.47]) and increased odds of hepatic- and cardiac-related events (OR = 1.74 [95% CI: 1.10-2.74]).

CONCLUSIONS

Chronic pain increased the risk of COVID-19 ED visits and hospitalizations. Presence of OUD further increased the risk of COVID-19 hospitalizations and the odds of hepatic- and cardiac-related events. Results highlight intersecting risks among a vulnerable population and can inform tailored COVID-19 management.

Perspectives on chronic musculoskeletal pain management among healthcare professionals in Bhutan: A qualitative study

INTRODUCTION

Musculoskeletal pain disorders continue to be one of the leading causes of disability worldwide. Best practice care recommends patient-centred biopsychosocial models of care. Little is known about the chronic musculoskeletal pain management in low- and middle-income countries.

OBJECTIVES

To explore the management of chronic musculoskeletal pain by healthcare professionals in Bhutan.

METHODS

This study employed a qualitative design involving 19 Bhutanese healthcare professionals managing chronic musculoskeletal pain in Bhutan. We collected data using a semi-structured interview guide. Thematic analysis was done manually.

RESULTS

Healthcare professionals reported that patients rely on a combination of home remedies and seek help from local healers and hospitals for chronic musculoskeletal pain management. While healthcare professionals understand chronic musculoskeletal pain as multi-dimensional phenomenon, the primary focus was on identifying and treating structural anomalies. Time constraints, inadequate knowledge and skills, lack of confidence, facilities and expertise were reported as barriers to the effective management of chronic musculoskeletal pain. They proposed a need for clinical guidelines, relevant skills training and creating awareness of chronic musculoskeletal pain.

CONCLUSION

The management of chronic musculoskeletal pain in Bhutan is focused on identifying and treating physical abnormalities. Healthcare professionals consider psychosocial dimensions important but lack any form of actionable interventions in this domain.

Race differences in pain and pain-related risk factors among former professional American-style football players

ABSTRACT

The burden of pain is unequal across demographic groups, with broad and persisting race differences in pain-related outcomes in the United States. Members of racial and ethnic minorities frequently report more pervasive and severe pain compared with those in the majority, with at least some disparity attributable to differences in socioeconomic status. Whether race disparities in pain-related health outcomes exist among former professional football players is unknown. We examined the association of race with pain outcomes among 3995 former professional American-style football players who self-identified as either Black or White. Black players reported more intense pain and higher levels of pain interference relative to White players, even after controlling for age, football history, comorbidities, and psychosocial factors. Race moderated associations between several biopsychosocial factors and pain; higher body mass index was associated with more pain among White but not among Black players. Fatigue and psychosocial factors were more strongly related to pain among Black players relative to White players. Collectively, the substantial social and economic advantages of working as a professional athlete did not seem to erase race-related disparities in pain. We highlight an increased burden of pain among elite Black professional football players and identify race-specific patterns of association between pain and biopsychosocial pain risk factors. These findings illuminate potential future targets of interventions that may serve to reduce persistent disparities in the experience and impact of pain.

Identifying populations with chronic pain in primary care: developing an algorithm and logic rules applied to coded primary care diagnostic and medication data

BACKGROUND

Estimates of chronic pain prevalence using coded primary care data are likely to be substantially lower than estimates derived from community surveys. Most primary care studies have estimated chronic pain prevalence using data searches confined to analgesic medication prescriptions. Increasingly, following recent NICE guideline recommendations, patients and doctors opt for non-drug treatment of chronic pain thus excluding these patients from prevalence estimates based on medication codes. We aimed to develop and test an algorithm combining medication codes with selected diagnostic codes to estimate chronic pain prevalence using coded primary care data.

METHODS

Following a scoping review 4 criteria were developed to identify cohorts of people with chronic pain. These were (1) people with one of 12 ('tier 1') conditions that almost always results in the individual having chronic pain (2) people with one of 20 ('tier 2') conditions included when there are also 3 or more prescription-only analgesics issued in the last 12 months (3) chronic neuropathic pain, or (4) 4 or more prescription-only analgesics issued in the last 12 months. These were translated into 8 logic rules which included 1,932 SNOMED CT codes.

RESULTS

The algorithm was run on primary care data from 41 GP Practices in Lambeth. The total population consisted of 386,238 GP registered adults ≥ 18 years as of the 31st March 2021. 64,135 (16.6%) were identified as people with chronic pain. This definition demonstrated notably high rates in Black ethnicity females, and higher rates in the most deprived, and older population.

CONCLUSIONS

Estimates of chronic pain prevalence using structured healthcare data have previously shown lower prevalence estimates for chronic pain than reported in community surveys. This has limited the ability of researchers and clinicians to fully understand and address the complex multifactorial nature of chronic pain. Our study demonstrates that it may be possible to establish more representative prevalence estimates using structured data than previously possible. Use of logic rules offers the potential to move systematic identification and population-based management of chronic pain into mainstream clinical practice at scale and support improved management of symptom burden for people experiencing chronic pain.

The mediating effect of allostatic load on the association between life course socioeconomic disadvantage and chronic pain: a prospective finding from the National Survey of Midlife Development in the United States

Background

Socioeconomic disadvantages (SEDs) are associated with chronic pain (CP) and allostatic load (AL). Few prospective population-based studies have examined the relationship between life course SED, CP interference, and CP widespreadness, and there is no prospective population-based study on whether AL mediates the association between SED and CP.

Objective

In this study, we investigated whether the prospective effect of SED on CP at Midlife in the United States (MIDUS) 3 is consistent with the accumulation of risk model and social mobility model, using the National Survey of MIDUS (n = 593). To prepare for the mediation analysis, we tested (1) whether SED would be prospectively associated with AL in the MIDUS 2 biomarker project, (2) whether AL would be prospectively associated with CP, and (3) whether childhood, as a critical period, moderated the association between AL and CP. In addition, the mediating effect of AL on the association between SED and CP was examined.

Method

SED was measured using cumulative scores and disadvantage trajectories derived from latent class trajectory modeling (LCTM). After multiple imputations, analyses were conducted using multinomial logistic regression for CP and negative binomial regression for AL, respectively. Finally, mediation analyses and moderated mediation analyses were performed.

Results

LCTM identified three SED trajectories, namely, constant low, high to low, and medium to high. The results showed that proximal cumulative SED was associated with high-interference CP. Furthermore, compared with the group with constant low SED, the group with medium-to-high SED was significantly associated with high-interference pain and experienced pain in at least three different sites. Cumulative SED and deteriorating SED trajectories were associated with higher AL, consistent with previous studies. Furthermore, childhood SED moderated the effect of AL on CP widespreadness and unexpectedly demonstrated a protective effect, while other associations between AL and CP were not significant. Subsequent mediation analysis did not yield statistically significant evidence.

Conclusions

People who experienced more recent SED or increasing disadvantage throughout their lives were more likely to suffer from CP, and this association was not mediated by physiological system dysregulation caused by chronic stress. Therefore, measures to alleviate AL may not be effective in protecting socioeconomically disadvantaged populations from CP.

Predictors of high-cost patients with acute whiplash-associated disorder in Japan

INTRODUCTION

The proportion of neck injuries due to traffic accidents is increasing. Little is known about high-cost patients with acute whiplash-associated disorder (WAD). The present study aimed to investigate whether time to first visit for conventional medicine, multiple doctor visits, or alternative medicine could predict high-cost patients with acute WAD in Japan.

METHODS

Data from a compulsory, no-fault, government automobile liability insurance agency in Japan between 2014 and 2019 were used. The primary economic outcome was the total cost of healthcare per person. Treatment-related variables were assessed based on the time to first visit for conventional and alternative medicine, multiple doctor visits, and visits for alternative medicine. Patients were categorized according to total healthcare cost (low, medium, and high cost). The variables were subjected to univariate and multivariate analysis to compare high-cost and low-cost patients.

RESULTS

A total of 104,911 participants with a median age of 42 years were analyzed. The median total healthcare cost per person was 67,366 yen. The cost for consecutive medicine, for consecutive and alternative medicine, and total healthcare costs were significantly associated with all clinical outcomes. Female sex, being a homemaker, a history of WAD claim, residential area, patient responsibility in a traffic accident, multiple doctor visits, and visits for alternative medicine were identified as independent predictive factors for a high cost in multivariate analysis. Multiple doctor visits and visits for alternative medicine showed large differences between groups (odds ratios 2673 and 694, respectively). Patients with multiple doctor visits and visits for alternative medicine showed a significantly high total healthcare cost per person (292,346 yen) compared to those without (53,587 yen).

CONCLUSIONS

A high total healthcare cost is strongly associated with multiple doctor visits and visits for alternative medicine in patients with acute WAD in Japan.

Original Research: The Impact of COVID-19 on Pain Care Among Older Adults

PURPOSE

In this qualitative descriptive study, we sought to understand the professional experiences and perceptions of pain management nurses who cared for older adults in the United States during the height of the COVID-19 pandemic.

METHODS

Data were collected between July 2020 and July 2021 through individual, semistructured interviews with a nonprobability sample of 18 pain management nurses. An inductive content analysis approach, in which categories were derived from a coding process based on a close reading of data extracts from the interview transcripts, was used to reveal the major theme related to the study aim.

RESULTS

Notwithstanding the variable consequences of COVID-19 on patients' health, a single overarching theme was pronounced: "Pain management for older adults remained unchanged during the pandemic despite unpredictable survival, restrictions on human interactions, and communication challenges." This theme was supported by four categories that emerged from the data: unpredictable survival, restriction-induced isolation, perceived continuity and equality of pain management, and communication challenges.

CONCLUSIONS

During the COVID-19 pandemic, pain management nurses stepped in and joined interdisciplinary teams providing general and specialized pain care to ensure that older adults, whether inpatient or outpatient, continued to receive quality care. These study findings highlight the many challenges pain management nurses faced during this unprecedented public health crisis, as well as opportunities to improve the health system and enhance nursing practice to meet the needs of older patients.

Ketamine-assisted psychotherapy treatment of chronic pain and comorbid depression: a pilot study of two approaches

Chronic pain and depression diagnoses are skyrocketing. There is an urgent need for more effective treatments. Ketamine was recently established to alleviate pain and depression, but many gaps remain in the scientific literature. This paper reports the findings of an observational preliminary study that explored the efficacy of ketamine-assisted psychotherapy (KAPT) for chronic pain/major depressive disorder (MDD) comorbidity. Researchers evaluated two KAPT approaches to determine optimal route of administration/dose. Ten individuals diagnosed with a chronic pain disorder and MDD receiving KAPT were recruited: five individuals pursuing the psychedelic approach (high doses administered intramuscularly 24 h before therapy) and five individuals pursuing the psycholytic approach (low doses administered sublingually via oral lozenges during therapy). To evaluate differences between altered states of consciousness each approach induces, participants completed the Mystical Experience Questionnaire (MEQ30) after their first (T-1), third (T-2) and sixth/final (T-3) treatment sessions. Primary outcomes were change in Beck Depression Inventory (BDI) scores and Brief Pain Inventory (BPI) Short Form scores from baseline (T0) to (T-1)-(T-3). Secondary outcomes were changes in Generalized Anxiety Disorder (GAD-7) Scale scores and Post-Traumatic Stress Disorder Checklist (PCL-5) scores at each timepoint. Statistically significant differences between each approach were not observed, but the small sample's limited statistical power makes changes seen worth noting. All participants' symptoms declined throughout treatment. Psychedelic treatment participants saw a larger, more consistent decrease. Researchers conclude that KAPT may be effective for treating chronic pain/MDD comorbidity, anxiety and Post-Traumatic Stress Disorder (PTSD). Findings imply that the psychedelic approach may be more effective. This pilot study serves as a basis for more extensive research that will inform how clinicians administer treatment to optimize outcomes.

A historical review of pain disparities research: Advancing toward health equity and empowerment

BACKGROUND AND PURPOSE

This theory-guided review draws on 30 years of published data to examine and interrogate the current and future state of pain disparities research.

METHODS

Using the Hierarchy of Health Disparity Research framework, we synthesize and present an overview of "three generations" of pain disparities scholarship, while proposing directions for adopting a "fourth generation" that redefines, explains, and theorizes future pain disparities research in a diverse society.

DISCUSSION

Prior research has focused on describing the scope of disparities, and throughout the historical context of human existence, racialized groups have been subjected to inadequate pain care. It is imperative that research not only illuminates existing problems but also provides solutions that can be implemented and sustained across varying social milieus.

CONCLUSION

We must invest in new theoretical models that expand on current perspectives and ideals that position all individuals at the forefront of justice and equity in their health.

Seventeen-Year National Pain Prevalence Trends Among U.S. Military Veterans

Importance

U.S. military veterans experience higher pain prevalence and severity than nonveterans. However, it is unclear how these differences have changed over time. Previous studies are limited to veterans receiving care from the Veterans Health Administration.

Objective

To characterize pain prevalence trends in the overall population of U.S. veterans compared to nonveterans, using nationally-representative data.

Design

Repeated cross-sectional study. Data: National Health Interview Survey, 2002-2018. Analysis: January 2023.

Setting

Population-based survey of noninstitutionalized U.S. adults.

Participants

Across the 17-year period, mean annual weighted population was 229.7 million adults (unweighted sample total: n=506,639; unweighted sample annual mean: n=29,802).

Exposure

Veteran status.

Main Outcomes

Crude and demographics-adjusted pain prevalence trend differences between veterans and nonveterans across five pain variables (severe headache or migraine, facial pain, neck pain, low back pain, and joint pain) and two composite variables (any pain [≥1 prevalent pain] and multiple pains [≥2 prevalent pains]).

Results

Weighted proportion of veterans varied from 11.48% in 2002 (highest) to 8.41% in 2017 (lowest). Across the study period, crude prevalence was generally similar or higher among veterans than nonveterans for all pain variables except for severe headache or migraine and facial pain. When equalizing age, sex, race, and ethnicity, pain prevalence among veterans remained similar or higher than nonveterans for all pain variables. From 2002 to 2018 there was an absolute increase (95% CI) in pain prevalence among veterans (severe headache or migraine: 2.0% [1.6% to 2.4%]; facial pain: 1.9% [1.4% to 2.4%]; neck pain: 4.7% [4.1% to 5.2%]; joint pain: 11.4% [10.8% to 11.9%]; low back pain: 10.3% [9.5% to 11.1%]; any pain: 10.0% [9.6% to 10.4%]; and multiple pains: 9.9% [9.2% to 10.6%]. Crude and adjusted analyses indicated prevalence of all pain variables increased more among veterans than nonveterans from 2002 to 2018.

Conclusion and Relevance

Veterans had similar or higher adjusted prevalence and higher rates of increase over time for all pain variables compared to nonveterans. Continued pain prevalence increase among veterans may impact healthcare utilization (within and outside of the VHA), underscoring the need for improved pain prevention and care programs for these individuals with disproportionate pain burden.

State Cannabis Legalization and Cannabis Use Disorder in the US Veterans Health Administration, 2005 to 2019

Importance

Cannabis use disorder (CUD) is increasing among US adults. Few national studies have addressed the role of medical cannabis laws (MCLs) and recreational cannabis laws (RCLs) in these increases, particularly in patient populations with high rates of CUD risk factors.

Objective

To quantify the role of MCL and RCL enactment in the increases in diagnosed CUD prevalence among Veterans Health Administration (VHA) patients from 2005 to 2019.

Design, Setting, and Participants

Staggered-adoption difference-in-difference analyses were used to estimate the role of MCL and RCL in the increases in prevalence of CUD diagnoses, fitting a linear binomial regression model with fixed effects for state, categorical year, time-varying cannabis law status, state-level sociodemographic covariates, and patient age group, sex, and race and ethnicity. Patients aged 18 to 75 years with 1 or more VHA primary care, emergency department, or mental health visit and no hospice/palliative care within a given calendar year were included. Time-varying yearly state control covariates were state/year rates from American Community Survey data: percentage male, Black, Hispanic, White, 18 years or older, unemployed, income below poverty threshold, and yearly median household income. Analysis took place between February to December 2022.

Main Outcomes and Measures

As preplanned, International Classification of Diseases, Clinical Modification, ninth and tenth revisions, CUD diagnoses from electronic health records were analyzed.

Results

The number of individuals analyzed ranged from 3 234 382 in 2005 to 4 579 994 in 2019. Patients were largely male (94.1% in 2005 and 89.0% in 2019) and White (75.0% in 2005 and 66.6% in 2019), with a mean (SD) age of 57.0 [14.4] years. From 2005 to 2019, adjusted CUD prevalences increased from 1.38% to 2.25% in states with no cannabis laws (no CLs), 1.38% to 2.54% in MCL-only enacting states, and 1.39% to 2.56% in RCL-enacting states. Difference-in-difference results indicated that MCL-only enactment was associated with a 0.05% (0.05-0.06) absolute increase in CUD prevalence, ie, that 4.7% of the total increase in CUD prevalence in MCL-only enacting states could be attributed to MCLs, while RCL enactment was associated with a 1.12% (95% CI, 0.10-0.13) absolute increase in CUD prevalence, ie, that 9.8% of the total increase in CUD prevalence in RCL-enacting states could be attributed to RCLs. The role of RCL in the increases in CUD prevalence was greatest in patients aged 65 to 75 years, with an absolute increase of 0.15% (95% CI, 0.13-0.17) in CUD prevalence associated with RCLs, ie, 18.6% of the total increase in CUD prevalence in that age group.

Conclusions and Relevance

In this study of VHA patients, MCL and RCL enactment played a significant role in the overall increases in CUD prevalence, particularly in older patients. However, consistent with general population studies, effect sizes were relatively small, suggesting that cumulatively, laws affected cannabis attitudes diffusely across the country or that other factors played a larger role in the overall increases in adult CUD. Results underscore the need to screen for cannabis use and CUD and to treat CUD when it is present.

Increasing pain prevalence and intensity among middle-aged and older adults: Evidence from the German Ageing Survey

OBJECTIVE

Pain is a very common chronic condition in late life that is associated with poorer quality of life and greater functional restrictions. Little is known regarding temporal trends in pain prevalence and pain intensity. Therefore, we estimated trends in pain prevalence and intensity over time among German middle-aged and older adults.

METHODS

We used two independent samples drawn in different years from the German Ageing Survey, which is a nationwide population-representative study with a cohort-sequential design. Specifically, a sample of individuals aged 40-85 years who were assessed in 2008 (n = 5961) was compared with a sample of individuals with the same age range who were assessed in 2014 (n = 5809). Individuals were asked if and to what extent they had experienced constant or recurrent pain within the past four weeks. χ² tests and regression analyses were computed.

RESULTS

In 2008, about 44% of all individuals reported suffering from at least very mild pain. In 2014, this proportion was higher by about 7%. Controlling for chronological age, gender, education, region of residence (West vs. East Germany), depressive symptoms, chronic diseases, BMI, and physical activity, the difference in pain prevalence and pain intensity between the samples remained statistically significant.

CONCLUSION

Our data suggest an increase in the prevalence and intensity of pain among middle-aged and older German adults between 2008 and 2014, which remained statistically significant when controlling for socio-demographic and health-related indicators. Further research is needed to identify the factors underlying this increasing pain prevalence and pain intensity in order to counteract this negative temporal trend.

Optimizing and Accelerating the Development of Precision Pain Treatments for Chronic Pain: IMMPACT Review and Recommendations

Large variability in the individual response to even the most-efficacious pain treatments is observed clinically, which has led to calls for a more personalized, tailored approach to treating patients with pain (ie, "precision pain medicine"). Precision pain medicine, currently an aspirational goal, would consist of empirically based algorithms that determine the optimal treatments, or treatment combinations, for specific patients (ie, targeting the right treatment, in the right dose, to the right patient, at the right time). Answering this question of "what works for whom" will certainly improve the clinical care of patients with pain. It may also support the success of novel drug development in pain, making it easier to identify novel treatments that work for certain patients and more accurately identify the magnitude of the treatment effect for those subgroups. Significant preliminary work has been done in this area, and analgesic trials are beginning to utilize precision pain medicine approaches such as stratified allocation on the basis of prespecified patient phenotypes using assessment methodologies such as quantitative sensory testing. Current major challenges within the field include: 1) identifying optimal measurement approaches to assessing patient characteristics that are most robustly and consistently predictive of inter-patient variation in specific analgesic treatment outcomes, 2) designing clinical trials that can identify treatment-by-phenotype interactions, and 3) selecting the most promising therapeutics to be tested in this way. This review surveys the current state of precision pain medicine, with a focus on drug treatments (which have been most-studied in a precision pain medicine context). It further presents a set of evidence-based recommendations for accelerating the application of precision pain methods in chronic pain research. PERSPECTIVE: Given the considerable variability in treatment outcomes for chronic pain, progress in precision pain treatment is critical for the field. An array of phenotypes and mechanisms contribute to chronic pain; this review summarizes current knowledge regarding which treatments are most effective for patients with specific biopsychosocial characteristics.

Biological Correlates of the Effects of Auricular Point Acupressure on Pain

BACKGROUND

To identify candidate inflammatory biomarkers for the underlying mechanism of auricular point acupressure (APA) on pain relief and examine the correlations among pain intensity, interference, and inflammatory biomarkers.

DESIGN

This is a secondary data analysis.

METHODS

Data on inflammatory biomarkers collected via blood samples and patient self-reported pain intensity and interference from three pilot studies (chronic low back pain, n = 61; arthralgia related to aromatase inhibitors, n = 20; and chemotherapy-induced neuropathy, n = 15) were integrated and analyzed. This paper reports the results based on within-subject treatment effects (change in scores from pre- to post-APA intervention) for each study group (chronic low back pain, cancer pain), between-group differences (changes in scores from pre- to post-intervention between targeted-point APA [T-APA] and non-targeted-point APA [NT-APA]), and correlations among pain intensity, interference, and biomarkers.

RESULTS

Within-group analysis (the change score from pre- to post-APA) revealed statistically significant changes in three biomarkers: TNF-α (cancer pain in the APA group, p = .03), β-endorphin (back pain in the APA group, p = .04), and IL-2 (back pain in the NT-APA group, p = .002). Based on between-group analysis in patients with chronic low back pain (T-APA vs NT-APA), IL-4 had the largest effect size (0.35), followed by TNF-α (0.29). A strong positive monotonic relationship between IL-1β and IL-2 was detected.

CONCLUSIONS

The current findings further support the potential role of inflammatory biomarkers in the analgesic effects of APA. More work is needed to gain a comprehensive understanding of the underlying mechanisms of APA on chronic pain. Because it is simple, inexpensive, and has no negative side effects, APA can be widely disseminated as an alternative to opioids.

Factors associated with frequent or daily use of prescription opioids among adults with chronic pain in the United States

OBJECTIVES

We aimed to estimate utilization rates of prescription opioids among adults with chronic pain in the United States (US) and identify factors associated with the frequent or daily use of prescription opioids.

METHODS

This was a case-control analysis of the 2019 National Health Interview Survey of adults.

RESULTS

Over 50.2 million adults in the US reported chronic pain in the past 3 months, but only 10.5% of this group said they used prescription opioids frequently or daily to manage their pain. Adults with chronic pain were significantly more likely to use opioids if they had incomes below the federal poverty level (15.7%), relied on public health insurance (14.8%), had been hospitalized in the past year (17.8%), or rated their health as fair or poor (18.4%). The highest rates of opioid use were reported among adults with severe (24.4%) or moderate disability (18.9%).

CONCLUSIONS

Approximately 5.3 million adults use prescription opioids frequently or daily to manage chronic pain. These individuals should receive regular clinical assistance to manage their pain, including medication management and, when appropriate, referral to evidence-based treatment programs for opioid use disorder.

An Analysis of the Role of Mental Health in a Randomized Trial of a Walking Intervention for Black Veterans With Chronic Pain

Black patients and those with co-occurring mental health disorders are disproportionately affected by chronic pain, but few interventions target these populations. This is a secondary analysis of a randomized trial of a walking-focused proactive counseling intervention for Black Veterans with chronic musculoskeletal pain (ACTION). The primary aim was to examine intervention effectiveness among Veterans with an electronic health record-documented mental health diagnosis [depressive disorder, anxiety disorder, substance use disorder, post-traumatic stress disorder or serious mental illness (n = 205)] and those without a diagnosis (n = 175). About 380 Black Veterans receiving care at the Atlanta VA Health Care System were enrolled from 2016 to 2019 and randomized to the intervention or usual care (UC) (1:1). The intervention featured 6 telephone coaching sessions over 8-14 weeks to encourage walking. Participants with a mental health disorder were more likely to complete all counseling sessions (56% vs 38%) and reported improvements in global perceptions of pain and pain intensity/interference (secondary outcomes) at 3-months vs UC. Among participants without a mental health disorder, the intervention was associated with an improvement in pain-related disability at 6-months (primary outcome). Black chronic pain patients with co-occurring mental health disorders may require more intensive treatment to affect improvement in pain-related disability. PERSPECTIVE: This study examines the effectiveness of a walking intervention for chronic pain among Black Veterans with a mental health disorder. These patients were more engaged with the intervention than those without a mental health disorder. However, they did not experience reductions in pain-related disability, suggesting more intensive treatment is needed.

A Cross-Sectional and Longitudinal Study of Pain among Middle-Aged and Older Adults in Thailand

Objective

The present study aimed to assess the prevalence and risk factors of pain among ageing adults in Thailand.

Methods

Cross-sectional and longitudinal data were analysed from two consecutive national waves of the Health, Aging, and Retirement in Thailand (HART) study in 2015 and 2017. The dependent variable pain was defined as moderate or severe pain in any of the 13 areas of the body over the past month. Independent variables included sociodemographic factors, health risk behaviour, physical and mental health conditions, and healthcare utilization.

Results

The baseline or cross-sectional sample consisted of 5,616 participants (≥45 years), and the follow-up or incident sample consisted of 2,305 participants. The proportion of pain in the cross-sectional/baseline sample was 36.0%, and in the incident/follow-up sample 39.9%. In the cross-sectional/baseline multivariable model, poor self-reported mental health, sleep problem, arthritis or rheumatism, brain disease and/or psychiatric problems, lung disease, use of hospital in-patient, conventional out-patient, and traditional medicine practitioners were positively associated with pain. In the incident/follow-up multivariable model, older age, Buddhist religion, class I obesity, poor self-reported mental health, hospital in-patient, private clinic out-patient, and use of a practitioner of traditional medicine were positively associated with pain. Male sex and higher education were negatively associated with both cross-sectional and incident pain.

Conclusions

More than one-third of older adults in Thailand had past month moderate or severe pain. Risk factors of pain from cross-sectional and/or incident analysis included older age, female sex, lower education, obesity, poor self-reported mental health, sleep problem, arthritis or rheumatism, brain disease and/or psychiatric problems, lung disease, and conventional and traditional healthcare utilization.

The Geography of Pain in the United States and Canada

Pain epidemiologists have, thus far, devoted scant attention to geospatial analyses of pain.  Both cross-national and, especially, subnational variation in pain have been understudied, even though geographic comparisons could shed light on social factors that increase or mitigate pain. This study presents the first comparative analysis of pain in the U.S. and Canada, comparing the countries in aggregate, while also analyzing variation across states and provinces. Analyses are based on cross-sectional data collected in 2020 from U.S. and Canadian adults 18 years and older (N = 4,113). The focal pain measure is a product of pain frequency and pain interference. We use decomposition and regression analyses to link socioeconomic characteristics and pain, and inverse-distance weighting spatial interpolation to map pain levels. We find significantly and substantially higher pain in the U.S. than in Canada. The difference is partly linked to Americans' worse economic conditions. Additionally, we find significant pain variability within the U.S. and Canada. U.S. states in the Deep South, Appalachia, and parts of the West stand out as pain 'hotspots' with particularly high pain levels. Overall, our findings identify areas with a high need for pain prevention and management; they also urge further scholarship on geographic factors as important covariates in population pain. PERSPECTIVE: This study documents the high pain burden in the U.S. versus Canada, and points to states in the Deep South, Appalachia, and parts of the West as having particularly high pain burden. The findings identify geographic areas with a high need for pain prevention and management.

Pain trends and pain growth disparities, 2009-2021

Physical pain is a major public health concern. Yet evidence on trends in physical pain around the world barely exists. Using nationally representative data from 146 countries (N = 1.6 million respondents), this paper finds that, all over the world, the percentage of people in pain increased from 26.3 in 2009 to 32.1 in 2021. This rising trend was present in both higher- and lower-income countries. This article also documents pain disparities: In the worldwide population, pain grew faster among women, the less educated, and the poor. Although the aggregate level of pain was greater among the elderly (> 60 years old), the growth in pain was faster among the younger (< 35 years old). These findings hold after controlling for sociodemographic factors. Disparities of pain growth in higher- and lower-income nations and potential explanatory factors are also discussed. Understanding how the level of pain varies over time and across demographic groups is crucial to evaluate and shape public health policies.

Trends in the Use of Opioids vs Nonpharmacologic Treatments in Adults With Pain, 2011-2019

IMPORTANCE

Chronic pain prevalence among US adults increased between 2010 and 2019. Yet little is known about trends in the use of prescription opioids and nonpharmacologic alternatives in treating pain.

OBJECTIVES

To compare annual trends in the use of prescription opioids, nonpharmacologic alternatives, both treatments, and neither treatment; compare estimates for the annual use of acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy; and estimate the association between calendar year and pain treatment based on the severity of pain interference.

DESIGN, SETTING, AND PARTICIPANTS

A serial cross-sectional analysis was conducted using the nationally representative Medical Expenditure Panel Survey to estimate the use of outpatient services by cancer-free adults with chronic or surgical pain between calendar years 2011 and 2019. Data analysis was performed from December 29, 2021, to August 5, 2022.

EXPOSURES

Calendar year (2011-2019) was the primary exposure.

MAIN OUTCOMES AND MEASURES

The association between calendar year and mutually exclusive pain treatments (opioid vs nonpharmacologic vs both vs neither treatment) was examined. A secondary outcome was the prevalence of nonpharmacologic treatments (acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy). All analyses were stratified by pain type.

RESULTS

Among the unweighted 46 420 respondents, 9643 (20.4% weighted) received surgery and 36 777 (79.6% weighted) did not. Weighted percentages indicated that 41.7% of the respondents were aged 45 to 64 years and 55.0% were women. There were significant trends in the use of pain treatments after adjusting for demographic factors, socioeconomic status, health conditions, and pain severity. For example, exclusive use of nonpharmacologic treatments increased in 2019 for both cohorts (chronic pain: adjusted odds ratio [aOR], 2.72; 95% CI, 2.30-3.21; surgical pain: aOR, 1.53; 95% CI, 1.13-2.08) compared with 2011. The use of neither treatment decreased in 2019 for both cohorts (chronic pain: aOR, 0.43; 95% CI, 0.37-0.49; surgical pain: aOR, 0.59; 95% CI, 0.46-0.75) compared with 2011. Among nonpharmacologic treatments, chiropractors and physical therapists were the most common licensed healthcare professionals.

CONCLUSIONS AND RELEVANCE

Among cancer-free adults with pain, the annual prevalence of nonpharmacologic pain treatments increased and the prevalent use of neither opioids nor nonpharmacologic therapy decreased for both chronic and surgical pain cohorts. These findings suggest that, although access to outpatient nonpharmacologic treatments is increasing, more severe pain interference may inhibit this access.

Diagnosing Prescription Opioid Use Disorder in Patients Using Prescribed Opioids for Chronic Pain

OBJECTIVE

The diagnostic criteria for opioid use disorder, originally developed for heroin, did not anticipate the surge in prescription opioid use and the resulting complexities in diagnosing prescription opioid use disorder (POUD), including differentiation of pain relief (therapeutic intent) from more common drug use motives, such as to get high or to cope with negative affect. The authors examined the validity of the Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 opioid version, an instrument designed to make this differentiation.

METHODS

Patients (N=606) from pain clinics and inpatient substance treatment who ever received a ≥30-day opioid prescription for chronic pain were evaluated for DSM-5 POUD (i.e., withdrawal and tolerance were not considered positive if patients used opioids only as prescribed, per DSM-5 guidelines) and pain-adjusted POUD (behavioral/subjective criteria were not considered positive if pain relief [therapeutic intent] was the sole motive). Bivariate correlated-outcome regression models indicated associations of 10 validators with DSM-5 and pain-adjusted POUD measures, using mean ratios for dimensional measures and odds ratios for binary measures.

RESULTS

The prevalences of DSM-5 and pain-adjusted POUD, respectively, were 44.4% and 30.4% at the ≥2-criteria threshold and 29.5% and 25.3% at the ≥4-criteria threshold. Pain adjustment had little effect on prevalence among substance treatment patients but resulted in substantially lower prevalence among pain treatment patients. All validators had significantly stronger associations with pain-adjusted than with DSM-5 dimensional POUD measures (ratios of mean ratios, 1.22-2.31). For most validators, pain-adjusted binary POUD had larger odds ratios than DSM-5 measures.

CONCLUSIONS

Adapting POUD measures for pain relief (therapeutic intent) improved validity. Studies should investigate the clinical utility of differentiating between therapeutic and nontherapeutic intent in evaluating POUD diagnostic criteria.

The experience of chronic pain among adolescents: suffering and attempt to overcome pain?

Background

Chronic pain (CP) among adolescents has received less attention than adultsandthere is limited qualitative studies about it in Iran. This study explored the experience of CP among adolescents.

Methods

This exploratory qualitative study was conducted in April–October 2019. Participants were 14 adolescent students purposively recruited from schools in Shiraz, Iran. Semi-structured interviews were conducted for data collection and data analysis was done through conventional content analysis.

Findings

Adolescents’ experiences of CP came into nine subcategories and three main categories, namely perceived suffering, attempt to overcome pain, and attempt to find sources of support.

Conclusion

Adolescents with CP experience physical and mental suffering and attempt to manage their pain and its associated suffering through different physical and psychological strategies and using different sources of support such as family, peers, healthcare providers, and school staff.

A Review of Potential National Chronic Pain Surveillance Systems in the United States

Pain has been established as a major public health problem in the United States (U.S.) with 50 million adults experiencing chronic pain and 20 million afflicted with high-impact chronic pain (ie, chronic pain that interferes with life or work activities). High financial and social costs are associated with chronic pain. Over the past 2 decades, pain management has been complicated by the marked increase in opioids prescribed to treat chronic noncancer pain and by the concurrent opioid crisis. Monitoring the prevalence of chronic pain and pain management is especially important because pain management is changing in uncertain ways. We review potential U.S. chronic pain surveillance systems, present potential difficulties of chronic pain surveillance, and explore how to address chronic pain surveillance in the current opioid era. We consider case definitions, severity, anatomic site, and varieties of chronic pain management strategies in reviewing and evaluating national surveys for chronic pain surveillance. Based on the criteria evaluated, the National Health Interview Survey offers the best single source for pain surveillance as the pain-related questions administered are brief, valid, and cover a broad scope of pain-related phenomena. PERSPECTIVE: This review article describes data sources that can be leveraged to conduct national chronic pain surveillance in the United States, explores case defining or pain-related questions administered, and evaluates them against 8 surveillance attributes.

Exploring the Feasibility of Virtually Delivered Auricular Point Acupressure in Self-Managing Chronic Pain: Qualitative Study

Background

Chronic pain remains highly prevalent. Current pharmacological and non-pharmacological strategies have not adequately managed chronic pain which has contributed to disability and high healthcare costs. With existing challenges in providing adequate pain care and access, we tested vAPA, a virtually delivered, self-management intervention using Auricular Point Acupressure (APA) by mobile app and virtual consultations (telehealth). Our key purpose was to evaluate the feasibility of the vAPA in self-managing chronic pain in preparation for a future randomized controlled trial.

Methods

We conducted a descriptive, qualitative study evaluating our 4-week vAPA intervention among 18 participants. We used directed qualitative content analysis. Results and Conclusion. Participants perceived that vAPA was feasible (acceptable, useable, practical, and beneficial). In addition, the following themes were gathered: better control of pain, less use of pain medications, self-management and motivation in pain, and expectations for pain relief. Refinements were recommended for the app, content, and delivery to improve study interventions. Findings are relevant in moving forward to a future randomized controlled trial and for wider implementation in a pragmatic clinical trial.

Physician Office Visits That Included Complementary Health Approaches in U.S. Adults: 2005-2015

Introduction: The Institute of Medicine has described the need for comparing models of care delivery involving complementary health approaches and conventional medical practitioners. As a step toward addressing this need, we used a nationally representative 11-year sample of office-based visits to physicians from the National Ambulatory Medical Care Survey (NAMCS), to examine a comprehensive list of factors believed to be associated with visits where complementary health approaches were recommended or provided. Methods: NAMCS is a national health care survey designed to collect data on the provision and use of ambulatory medical care services provided by office-based physicians in the United States. Patient medical records were abstracted from a random sample of office-based physician visits. We examined several visit characteristics, including patient demographics, physician specialty, documented health conditions, and reasons for health visit. We ran chi-square analyses to test bivariate associations between visit factors and whether complementary health approaches were recommended or provided to guide development of logistic regression models. Results: Of the 550,114 office visits abstracted, 4.43% contained a report that complementary health approaches were ordered, supplied, administered, or continued. Among complementary health visits, 87% of patient charts mentioned nonvitamin nonmineral dietary supplements. The prevalence of complementary health visits significantly increased from 2% in 2005 to almost 8% in 2015. Returning patient status, survey year, physician specialty and degree, menopause, cardiovascular, and musculoskeletal diagnoses were significantly associated with complementary health visits, as was seeking preventative care or care for a chronic problem. Conclusion: We present an overview of the first study of office-based physician visits where complementary health approaches were recommended or ordered to their patients. These data confirm the growing popularity of complementary health approaches in the United States, provide a baseline for further studies, and inform subsequent investigations of integrative health care.

The Great Divide: Education, Despair, and Death

Deaths of despair, morbidity and emotional distress continue to rise in the US, largely borne by those without a college degree, the majority of American adults, for many of whom the economy and society are no longer delivering. Concurrently, all-cause mortality in the US is diverging by education in a way not seen in other rich countries. We review the rising prevalence of pain, despair, and suicide among those without a BA. Pain and despair created a baseline demand for opioids, but the escalation of addiction came from pharma and its political enablers. We examine the "politics of despair," how less-educated people have abandoned and been abandoned by the Democratic Party. While healthier states once voted Republican in presidential elections, now the less-healthy states do. We review deaths during COVID, finding mortality in 2020 replicated existing relative mortality differences between those with and without college degrees.

Pain Severity and Interference and Substance Use Among Community Pharmacy Patients Prescribed Opioids: A Secondary Analysis of the PHARMSCREEN Study

This secondary analysis examined relationships between pain severity and interference and substance use among patients filling opioid prescriptions in Indiana and Ohio community pharmacies (n = 1,461). We likewise sought to explore the moderating role of gender in pain-substance use relations. We used patient-reported data from a cross-sectional health survey linked with controlled substance dispensing data from statewide prescription drug monitoring programs. Multivariable logistic regression estimated associations between pain severity and interference and various indices of risky prescription opioid use and non-opioid substance use. Exploratory analyses examined whether gender moderated associations. Increased pain severity was associated with increased odds of moderate- to high-risk opioid use (OR: 1.23; 95% CI: 1.16-1.31) and opioid-benzodiazepine co-use (OR: 1.20; 95% CI: 1.03-1.40). Increased pain interference was associated with greater odds of receiving opioids from multiple pharmacies or providers (OR: 1.15; 95% CI: 1.01-1.31). Increased pain severity and interference were associated with higher odds of any tobacco use (severity: OR: 1.13; 95% CI: 1.06-1.21; interference: OR: 1.07; 95% CI: 1.01-1.12) and weekly to daily sedative use (severity: OR: 1.13; 95% CI: 1.03-1.25; interference: OR: 1.13; 95% CI: 1.04-1.22). Increased pain severity was associated with decreased odds of any alcohol use (OR: 0.93; 95% CI: 0.88-0.99). Gender was a significant effect modifier in associations between pain and alcohol, tobacco, and cannabis use. The study was registered in the database of clinicaltrials.gov (register number NCT03936985). Perspective: This study suggests that pain severity and interference are associated with increased use of non-medical prescription opioids, sedatives, and tobacco and decreased use of alcohol, in ways that are different between women and men. Findings may guide the development of gender-sensitive evidence-based strategies to ameliorate or prevent substance misuse among patients living with pain.

The Clash of Two Epidemics: the Relationship Between Opioids and Glucose Metabolism

PURPOSE OF REVIEW

We are currently in the midst of a global opioid epidemic. Opioids affect many physiological processes, but one side effect that is not often taken into consideration is the opioid-induced alteration in blood glucose levels.

RECENT FINDINGS

This review shows that the vast majority of studies report that opioid stimulation increases blood glucose levels. In addition, plasma levels of the endogenous opioid β-endorphin rise in response to low blood glucose. In contrast, in hyperglycaemic baseline conditions such as in patients with type 2 diabetes mellitus (T2DM), opioid stimulation lowers blood glucose levels. Furthermore, obesity itself alters sensitivity to opioids, changes opioid receptor expression and increases plasma β-endorphin levels. Thus, opioid stimulation can have various side effects on glycaemia that should be taken into consideration upon prescribing opioid-based medication, and more research is needed to unravel the interaction between obesity, glycaemia and opioid use.

Trends in Prescriptions for Non-opioid Pain Medications Among U.S. Adults With Moderate or Severe Pain, 2014-2018

As opioid prescribing has declined, it is unclear how the landscape of prescription pain treatment across the U.S. has changed. We used nationally-representative data from the Medical Expenditure Health Survey, 2014 to 2018 to examine trends in prescriptions for opioid and non-opioid pain medications, including acetaminophen, non-steroidal anti-inflammatory drugs, gabapentinoids, and antidepressants among U.S. adults with self-reported pain. Overall, from 2014 to 2018, the percentage of participants receiving a prescription for opioids declined, (38.8% vs 32.8%), remained stable for non-steroidal anti-inflammatory drugs (26.8% vs 27.7%), and increased for acetaminophen (1.6% vs 2.3%), antidepressants (9.6% vs 12.0%) and gabapentinoids (13.2% vs 19.0%). In this period, the adjusted odds of receiving an opioid prescription decreased (aOR = .93, 95% CI = .90-.96), while the adjusted odds of receiving antidepressant, gabapentinoid and acetaminophen prescriptions increased (antidepressants: aOR = 1.08, 95% CI = 1.03-1.13 gabapentinoids: aOR = 1.11, 95% CI = 1.06-1.17; acetaminophen: aOR = 1.10, 95% CI: 1.02-1.20). Secondary analyses stratifiying within the 2014 to 2016 and 2016 to 2018 periods revealed particular increases in prescriptions for gabapentinoids (aOR = 1.13, 95% CI = 1.05-1.21) and antidepressants (aOR = 1.23, 95% CI = 1.12-1.35) since 2016. PERSPECTIVE: These data demonstrate that physicians are increasingly turning to CDC-recommended non-opioid medications for pain management, particularly antidepressants and gabapentinoids. However, evidence for these medications' efficacy in treating numerous common pain conditions, including low back pain, remains limited.

Biomaterials and Regenerative Medicine in Pain Management

Purpose of Review

Pain presents a unique challenge due to the complexity of the biological pathways involved in the pain perception, the growing concern regarding the use of opioid analgesics, and the limited availability of optimal treatment options. The use of biomaterials and regenerative medicine in pain management is being actively explored and showing exciting progress in improving the efficacy of conventional pharmacotherapy and as novel non-pharmacological therapy for chronic pain caused by degenerative diseases. In this paper we review current clinical applications, and promising research in the use of biomaterials and regenerative medicine in pain management.

Recent Findings

Regenerative therapies have been developed to repair damaged tissues in back, joint, and shoulder that lead to chronic and inflammatory pain. Novel regenerative biomaterials have been designed to incorporate biochemical and physical pro-regenerative cues that augment the efficacy of regenerative therapies. New biomaterials improve target localization with improved tunability for controlled drug delivery, and injectable scaffolds enhance the efficacy of regenerative therapies through improving cellular migration. Advanced biomaterial carrier systems have been developed for sustained and targeted delivery of analgesic agents to specific tissues and organs, showing improved treatment efficacy, extended duration of action, and reduced dosage. Targeting endosomal receptors by nanoparticles has shown promising anti-nociception effects. Biomaterial scavengers are designed to remove proinflammatory reactive oxygen species that trigger nociceptors and cause pain hypersensitivity, providing a proactive approach for pain management.

Summary

Pharmacotherapy remains the method of choice for pain management; however, conventional analgesic agents are associated with adverse effects. The relatively short duration of action when applied as free drug limited their efficacy in postoperative and chronic pain treatment. The application of biomaterials in pain management is a promising strategy to improve the efficacy of current pharmacotherapy through sustained and targeted delivery of analgesic agents. Regenerative medicine strategies target the damaged tissue and provide non-pharmacological alternatives to manage chronic and inflammatory pain. In the future, the successful development of regenerative therapies that completely repair damaged tissues will provide a more optimal alternative for the treatment of chronic pain caused. Future studies will leverage on the increasing understanding of the molecular mechanisms governing pain perception and transmission, injury response and tissue regeneration, and the development of new biomaterials and tissue regenerative methods.

The Nexus of Physical and Psychological Pain: Consequences for Mortality and Implications for Medical Sociology

Although physical pain lies at the intersection of biology and social conditions, a sociology of pain is still in its infancy. We seek to show how physical and psychological pain are jointly parts of a common expression of despair, particularly in relation to mortality. Using the 2002-2014 National Health Interview Survey Linked Mortality Files (N = 228,098), we explore sociodemographic differences in the intersection of physical and psychological pain (referred to as the "pain-distress nexus") and its relationship to mortality among adults ages 25 to 64. Results from regression and event history models reveal that differences are large for the combination of the two, pointing to an overlooked aspect of health disparities. The combination of both high distress and high pain is most prevalent and most strongly predictive of mortality among socioeconomically disadvantaged, non-Hispanic whites. These patterns have several implications that medical sociology is well positioned to address.

Estimates of Probabilities of Successful Development of Pain Medications: An Analysis of Pharmaceutical Clinical Development Programs 2000-2020

BACKGROUND

We estimate the probability of successful development and duration of clinical trials for medications to treat neuropathic and nociceptive pain. We also consider the effect of the perceived abuse potential of the medication on these variables.

METHODS

This study uses the Citeline database to compute the probabilities of success, duration, and survivorship of pain medication development programs between January 1, 2000, and June 30, 2020, conditioned on the phase, type of pain (nociceptive vs. neuropathic), and the abuse potential of the medication.

RESULTS

The overall probability of successful development of all pain medications from phase 1 to approval is 10.4% (standard error (SE) of 1.5%). Medications to treat nociceptive and neuropathic pain have a probability of successful development of 13.1% (SE: 2.3%) and 7.1% (SE: 1.9%), respectively. The probability of successful development of medications with high abuse potential and low abuse potential are 27.8% (SE: 4.6%) and 4.7% (SE: 1.2%), respectively. The most common period for attrition is between phase 3 and approval.

DISCUSSION

Our data suggest that the unique attributes of pain medications, such as their abuse potential and intended pathology, can influence the probability of successful development and duration of development.

Trends in Prescription Opioid and Nonopioid Analgesic Use by Race, 1996-2017

INTRODUCTION

Identifying racial differences in trends in prescription opioid use (POU) is essential for formulating evidence-based responses to the opioid epidemic. This study analyzes trends in the prevalence of POU and exclusive nonopioid analgesic use (ENA) by race-ethnicity.

METHODS

The Medical Expenditure Panel Survey was used to examine analgesic use among civilian adults without cancer (age ≥18 years) between 1996 and 2017. The outcome classified individuals into 3 mutually exclusive categories of prescription analgesic use: no prescription analgesic, POU, and ENA. Analyses were conducted between December 2020 and April 2021.

RESULTS

Among 250,596 adults, baseline analgesic usage varied with race-ethnicity, where non-Hispanic Whites had the highest POU (11.9%), and it was as prevalent as ENA (11.3%). Non-Hispanic Blacks and Hispanics had lower POU at baseline (9.3% and 9.6%, respectively), and ENA exceeded POU. Subsequently, POU increased across race-ethnicity with concomitant decreases in ENA, eventually eclipsing ENA in Whites and Blacks but not among Hispanics. Although POU among Blacks became as prevalent as it was among Whites in the 2000s-2010s, POU among Hispanics remained lower than the other groups throughout the 2000s-2010s. After the adoption of prescribing limits, POU declined across race-ethnicity by comparable levels in 2016-2017.

CONCLUSIONS

Blacks and Hispanics were less likely to use opioids when they first became widely available for noncancer pain. Subsequently, POU displaced ENA among Whites and Blacks. Although POU is often associated with Whites, a significant proportion of the Black population may also be at risk. Finally, although lower POU among Hispanics may be protective of misuse, it could represent undertreatment.

Investigating Prescription Medication Expenditures and Level of Perceived Health Status among Older Adults with Pain in the United States

Background: the objective of this retrospective, cross sectional study was to assess the relationship between different levels of perceived health status and prescription medication expenditures among United States adults aged ≥50 years with self-reported pain. Methods: using 2019 Medical Expenditure Panel Survey (MEPS) data, four levels of perceived health status were formed (excellent, very good, good, and fair/poor health). Differences between characteristics in the groups were compared using chi square tests. Adjusted linear regression models, using logged positive annual prescription medication expenditures, were constructed to assess differences in prescription medication expenditures between levels of perceived health. Results: a total of 4826 individuals were included in the study. Adjusted linear regression analysis indicated those who reported excellent health had 65.8% lower annual prescription medication expenditures than those with fair/poor health. Those with very good health had 49.7% lower annual prescription medication expenditures than those with fair/poor health, while those with good health had 27.2% lower annual prescription medication expenditures than those with fair/poor health. Conclusions: better perceived health status was generally associated with relatively lower prescription medication expenditures. Further research is needed to investigate if this pattern is also observed for other categories of healthcare expenditures and in other populations.

Painful Truth: The Need to Re-Center Chronic Pain on the Functional Role of Pain

Pain is undesirable, whether it is a symptom of mild or severe illness or instead indicates disorder in the nervous system’s ability to perceive and process sensory information. Nonetheless, pain is part of the body’s ability to defend itself and promote its own survival—this is its fundamental evolutionary function. This normal expression of pain is not limited to what is considered useful because it alerts us to the initiation of illness. It also applies to pain that continues when illness or noxious stimuli persist. However, the parameters of what is here termed functional pain are not fully understood and are seldom explicitly the focus of research. This paper posits that failure to appreciate the functional role of pain in research has had significant unintended consequences and may be contributing to inconsistent research findings. To that end, the paper describes the misclassification issue at the core of chronic pain research—whether a given pain reflects functional or pathological processes—and discusses research areas where reconsidering the functional role of pain may lead to advancements.

Pain, cannabis use, and physical and mental health indicators among veterans and nonveterans: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III

ABSTRACT

Chronic pain is associated with mental and physical health difficulties and is prevalent among veterans. Cannabis has been put forth as a treatment for chronic pain, and changes in laws, attitudes, and use patterns have occurred over the past 2 decades. Differences in prevalence of nonmedical cannabis use and cannabis use disorder (CUD) were examined across 2 groups: veterans or nonveterans and those reporting or not reporting recent pain. Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013; n = 36,309) were analyzed using logistic regression. Prevalence differences (PDs) for 3 cannabis outcomes (1) past-year nonmedical cannabis use, (2) frequent (≥3 times a week) nonmedical use, and (3) DSM-5 CUD were estimated for those reporting recent moderate to severe pain (veterans or nonveterans) and veterans reporting or not reporting recent pain. Difference in differences was calculated to investigate PDs on outcomes associated with residence in a state with medical cannabis laws (MCLs). Associations between physical and mental health and cannabis variables were tested. The results indicated that the prevalence of recent pain was greater among veterans (PD = 7.25%, 95% confidence interval (CI) [4.90-9.60]). Among veterans, the prevalence of frequent cannabis use was greater among those with pain (PD = 1.92%, 98% CI [0.21-3.63]), and among veterans residing in a state with MCLs, the prevalence of CUD was greater among those reporting recent pain (PD = 3.88%, 98% CI [0.36-7.39]). Findings failed to support the hypothesis that cannabis use improves mental or physical health for veterans with pain. Providers treating veterans with pain in MCL states should monitor such patients closely for CUD.