Rethinking clinically significant pain: a marker of recovery rather than a warning of injury

The Association Between Chronic Pain, Substance use, and Primary Care Experience Among Veterans with Ongoing or Recent Homelessness

BACKGROUND

Chronic pain and problematic substance use are prevalent among Veterans with homeless experience (VHE) and may contribute to a challenging primary care experience.

OBJECTIVE

To examine the association of chronic pain and problematic substance use with unfavorable primary care experiences among VHE and to explore the association of pain treatment utilization and unfavorable care experiences in VHE with chronic pain.

METHODS

We surveyed VHE (n = 3039) engaged in homeless-tailored primary care at 29 Veterans Affairs Medical Centers (VAMCs). We assessed unfavorable primary care experiences with four validated Primary Care Quality-Homeless (PCQ-H) scales: multivariable logistic regressions explored associations between unfavorable care experiences for VHE with chronic pain and problematic substance use, chronic pain alone, problematic substance use alone, or neither. We then examined the association between receipt of pain treatments and unfavorable experiences among VHE with chronic pain. Last, we identified PCQ-H items that had the greatest difference in unfavorable response rates between VHE with and without chronic pain.

RESULTS

The prevalence of unfavorable primary care experience was higher on all four scales for patients reporting chronic pain (with or without problematic substance use) (all p < 0.001), but not for problematic substance use alone, compared to VHE with neither pain nor problematic substance use. In analyses limited to VHE with chronic pain, those on long-term opioids were less likely to report an unfavorable experience (OR = 0.49, 95%CI 0.34-0.69). Receipt of occupational therapy was associated with lower odds of reporting an unfavorable experience (OR = 0.83, 95%CI 0707-0.98). PCQ-H items related to trust, relationships, and provider communication had the greatest differences in dissatisfaction ratings (all p < 0.001).

CONCLUSIONS

Chronic pain is associated with unfavorable primary care experiences among VHE, potentially contributing to poor care outcomes. Strategies are needed to enhance patient-provider trust and communication and increase VHE's access to effective pain treatments.

Are opioids effective analgesics and is physiological opioid dependence benign? Revising current assumptions to effectively manage long-term opioid therapy and its deprescribing

A re-examination of clinical principles of long-term opioid therapy (LTOT) for chronic pain is long overdue amid the ongoing opioid crisis. Most patients on LTOT report ineffectiveness (poor pain control, function and health) but still find deprescribing challenging. Although prescribed as analgesics, opioids more likely provide pain relief primarily through reward system actions (enhanced relief and motivation) and placebo effect and less through antinociceptive effects. The unavoidable physiologic LTOT dependence can automatically lead to a paradoxical worsening of pain, disability and medical instability (maladaptive opioid dependence) without addiction due to allostatic opponent neuroadaptations involving reward/antireward and nociceptive/antinociceptive systems. This opioid-induced chronic pain syndrome (OICP) can persist/progress whether LTOT dose is maintained at the same level, increased, decreased or discontinued. Current conceptualization of LTOT as a straightforward long-term analgesic therapy appears incongruous in view of the complex mechanisms of opioid action, LTOT dependence and OICP. LTOT can be more appropriately conceptualized as therapeutic induction and maintenance of an adaptive LTOT dependence for functional improvement irrespective of analgesic benefits. Adaptive LTOT dependence should be ideally used for a limited time to achieve maximum functional recovery and deprescribed while maintaining functional gains. Patients on LTOT should be regularly re-evaluated to identify if maladaptive LTOT dependence with OICP has diminished any functional gains or leads to ineffectiveness. Ineffective LTOT (with maladaptive LTOT dependence) should be modified to make it safer and more effective. An adequately functional life without opioids is the ideal healthy long-term goal for both LTOT initiation and LTOT modification.

The Impact of Non-Pain Factors on Pain Interference Among U.S. Service Members and Veterans with Symptoms of Mild Traumatic Brain Injury

U.S. Service members and Veterans (SM/V) experience elevated rates of traumatic brain injury (TBI), chronic pain, and other non-pain symptoms. However, the role of non-pain factors on pain interference levels remains unclear among SM/Vs, particularly those with a history of TBI. The primary objective of this study was to identify factors that differentiate high/low pain interference, given equivalent pain intensity among U.S. SM/V participating in the ongoing Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) national multi-center prospective longitudinal observational study. An explainable machine learning was used to identify key predictors of pain interference conditioned on equivalent pain intensity. The final sample consisted of n = 1,577 SM/Vs who were predominantly male (87%), and 83.6% had a history of mild TBI(s) (mTBI), while 16.4% were TBI negative controls. The sample was categorized according to pain interference level (Low: 19.9%, Moderate: 52.5%, and High: 27.6%). Both pain intensity scores and pain interference scores increased with the number of mTBIs (p < 0.001), and there was evidence of a dose response between the number of injuries and pain scores. Machine learning models identified fatigue and anxiety as the most important predictors of pain interference, whereas emotional control was protective. Partial dependence plots identified that marginal effects of fatigue and anxiety were associated with pain interference (p < 0.001), but the marginal effect of mTBI was not significant in models considering all variables (p > 0.05). Non-pain factors are associated with functional limitations and disability experience among SM/V with an mTBI history. The functional effects of pain may be mediated through multiple other factors. Pain is a multi-dimensional experience that may benefit most from holistic treatment approaches that target comorbidities and build supports that promote recovery.