Drug dependence in patients with chronic pain: A retrospective study

Nationwide Assessment of Chronic Pain among Hospitalized Individuals with Co-occurring Post Traumatic Stress Disorder and Substance Use Disorder in the United States

Objective: Chronic pain (CP) is independently associated with substance use disorders (SUD) and posttraumatic stress disorder (PTSD). However, little is known about factors associated with CP among patients with co-occurring PTSD and SUD. Patterns of hospital resource usage should also be explored further. Methods: Using the 2019 National Inpatient Sample (NIS), we identified 216,125 hospital discharges with co-occurring diagnoses of PTSD and SUD in 2019 and examined their association with CP. Multivariable logistic regression models were used to identify factors associated with an increased likelihood of CP in this cohort. Results: Among those with co-occurring PTSD and SUD (N = 216,125), 35,450 had associated CP, a prevalence of 164.02 cases per 1,000 discharges (95% CI [160.54, 167.52]). Individuals aged 55-64 with co-occurring PTSD and SUD were approximately 7.2 times more likely to experience CP, compared to those aged 16-24 (OR = 7.2; 95% CI [6.09, 8.60]). Being in the CP group was associated with 50% increased odds of insomnia and obesity (OR = 1.5; 95% CI [1.12, 2.03] and OR = 1.5; 95% CI [1.38, 1.55], respectively), 30% increased odds of anxiety (OR = 1.3; 95% CI [1.24, 1.38]), 20% increased odds of attention deficit disorder (ADD;OR = 1.2; 95% CI [1.12, 1.38]) and 10% increased odds of depression (OR = 1.1; 95% CI [1.01, 1.14]). Compared with females, being male was associated with slightly decreased odds of CP (OR = 0.9; 95% CI [0.84, 0.94]). Conclusions: Among hospitalized Americans with co-occurring PTSD and SUD, advanced age, being female, and the presence other mental health disorders were associated with an increased risk of CP. Providers treating co-occurring PTSD/SUD should evaluate for and consider evidence-based management of CP if present.

Developing a Framework to Infer Opioid Use Disorder Severity From Clinical Notes to Inform Natural Language Processing Methods: Characterization Study

BACKGROUND

Information regarding opioid use disorder (OUD) status and severity is important for patient care. Clinical notes provide valuable information for detecting and characterizing problematic opioid use, necessitating development of natural language processing (NLP) tools, which in turn requires reliably labeled OUD-relevant text and understanding of documentation patterns.

OBJECTIVE

To inform automated NLP methods, we aimed to develop and evaluate an annotation schema for characterizing OUD and its severity, and to document patterns of OUD-relevant information within clinical notes of heterogeneous patient cohorts.

METHODS

We developed an annotation schema to characterize OUD severity based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. In total, 2 annotators reviewed clinical notes from key encounters of 100 adult patients with varied evidence of OUD, including patients with and those without chronic pain, with and without medication treatment for OUD, and a control group. We completed annotations at the sentence level. We calculated severity scores based on annotation of note text with 18 classes aligned with criteria for OUD severity and determined positive predictive values for OUD severity.

RESULTS

The annotation schema contained 27 classes. We annotated 1436 sentences from 82 patients; notes of 18 patients (11 of whom were controls) contained no relevant information. Interannotator agreement was above 70% for 11 of 15 batches of reviewed notes. Severity scores for control group patients were all 0. Among noncontrol patients, the mean severity score was 5.1 (SD 3.2), indicating moderate OUD, and the positive predictive value for detecting moderate or severe OUD was 0.71. Progress notes and notes from emergency department and outpatient settings contained the most and greatest diversity of information. Substance misuse and psychiatric classes were most prevalent and highly correlated across note types with high co-occurrence across patients.

CONCLUSIONS

Implementation of the annotation schema demonstrated strong potential for inferring OUD severity based on key information in a small set of clinical notes and highlighting where such information is documented. These advancements will facilitate NLP tool development to improve OUD prevention, diagnosis, and treatment.

Pain Catastrophizing Scale Associated With Other Patient-Reported Outcome Measures in Plantar Fasciitis and Chronic Ankle Instability Patients

BACKGROUND

The Pain Catastrophizing Scale (PCS) is a measure of how patients emotionally respond to pain. It is composed of 3 subscales-rumination, magnification, and helplessness-which address intrusive thoughts of pain, expectations of negative outcomes, and inability to cope with pain. Our purpose is to compare baseline PCS scores with other baseline patient-reported outcome measures (PROMs) in patients with plantar fasciitis (PF) or chronic ankle instability (CAI).

METHODS

We retrospectively reviewed 201 patients who reported at least 1 pretreatment PCS subscore and were diagnosed with PF or CAI between 2015 and 2020 in a single fellowship-trained foot and ankle surgeon's clinic. Demographics, comorbidities, treatments, other baseline PROMs (i.e., visual analog scale [VAS], Pain Disability Index [PDI], 12-Item Short Form Survey [SF-12], 8-Item Somatic Symptom Scale [SSS-8]), and postoperative outcomes were recorded.

RESULTS

The PCS total score and its subscores significantly correlated with the total score and/or subscores of each PROM. Higher PCS total score significantly correlated with worse VAS (P<.001), SF-12 mental (P=.007), PDI total (P<.001), and SSS-8 (P<.001) scores. Only the PCS magnification subscore was significantly greater among patients who did (n=41) undergo surgery (P=.043). Those who had previously undergone foot and/or ankle surgery had significantly higher PCS rumination (P=.012), magnification (P=.006), helplessness (P=.008), and total (P=.003) scores. Likewise, those with a history of substance abuse also had significantly higher PCS scores (P=.005; P=.003; P=.006; P=.003).

CONCLUSION

The correlations between PCS scores and other baseline PROMs indicate that strong pain catastrophizers with PF or CAI may be at risk for poor treatment outcomes. PCS scores could be used to help with treatment for such high-risk patients.

Substance use and common contributors to morbidity: A genetics perspective

Excessive substance use and substance use disorders (SUDs) are common, serious and relapsing medical conditions. They frequently co-occur with other diseases that are leading contributors to disability worldwide. While heavy substance use may potentiate the course of some of these illnesses, there is accumulating evidence suggesting common genetic architectures. In this narrative review, we focus on four heritable medical conditions - cardiometabolic disease, chronic pain, depression and COVID-19, which are commonly overlapping with, but not necessarily a direct consequence of, SUDs. We find persuasive evidence of underlying genetic liability that predisposes to both SUDs and chronic pain, depression, and COVID-19. For cardiometabolic disease, there is greater support for a potential causal influence of problematic substance use. Our review encourages de-stigmatization of SUDs and the assessment of substance use in clinical settings. We assert that identifying shared pathways of risk has high translational potential, allowing tailoring of treatments for multiple medical conditions.

Funding

SSR acknowledges T29KT0526, T32IR5226 and DP1DA054394; RLK acknowledges AA028292; AA acknowledges DA054869 & K02DA032573. The funders had no role in the conceptualization or writing of the paper.

Chronic Lumbar Pain and Insomnia in College-Aged Students

Insomnia in college students has a significant impact on academic performance and mental health (e.g., depression). Although the mechanisms underlying insomnia and chronic pain are becoming clearer, only a few studies on college students have examined these factors by their location in the body. The purpose of the present study was to identify the location of chronic pain in the body most associated with insomnia in college students. A web-based survey was used to collect information pertaining to nine questions from 494 university students: sex, age, presence of chronic pain, intensity of chronic pain, location of chronic pain, and duration of chronic pain, as well as scores from the Athens Insomnia Scale (AIS), Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale. To examine the association between insomnia and the site of chronic pain, stepwise logistic regression analysis was conducted with AIS as the target variable. The results showed a significant positive correlation between chronic pain in the lumbar region and AIS scores. Future longitudinal studies including multiple factors are necessary to clarify the causal relationship between insomnia and chronic lower back pain.

Chronic pain and delinquency partially explain the effect of the DRD4 gene polymorphism on adult substance use

Background: The dopamine receptor D4 [DRD4] has been reported to be associated with substance use. Yet, the roles that health conditions and behaviors may play in such association are understudied.Objective: This longitudinal study investigated the potential mediation effects of chronic pain and delinquency in adolescence on the association between the DRD4 2-repeat allele and substance use in adulthood. Sex, witnessing violence, and experiencing violence were also examined as potential moderators for the mediation pathways.Methods: We used the restricted and candidate gene data from the National Longitudinal Study of Adolescent to Adult Health (Waves I-IV) to conduct secondary analysis (N = 8,671; 47% male). A two-step approach was adopted to examine the mediation effects regarding four substance use outcomes in adulthood: number of lifetime alcohol use disorder symptoms, lifetime regular smoker status, past-month smoking, and lifetime "pain killer" misuse. The moderation effects were investigated using stratification and permutation.Results: The DRD4 2-repeat allele was associated with all adulthood substance use outcomes through adolescent chronic pain and delinquency (AORs/IRR range 1.08-3.78; all ps<0.01). The association between delinquency and smoking was higher among females. The association between delinquency and substance use was lower among the participants who witnessed violence in adolescence.Conclusions: This study identified modifiable mediators underlying the association between the DRD4 2-repeat allele and substance use behaviors, concluding that chronic pain and delinquency partially explain the effect of the DRD4 gene polymorphism on adult substance use.

Patient-reported factors associated with degree of pain medication dependence and presence of severe dependence among spinal outpatients

Aim: To identify risk factors for pain medication dependence. Materials & methods: Chronic spinal pain outpatients (n = 106) completed the Leeds Dependence Questionnaire (LDQ) and measures of potential risk factors. Participants with high (n = 3) and low (n = 3) dependence were interviewed. Results: Mean LDQ score was 11.52 (standard deviation 7.35) and 15/106 participants (14.2%) were severely dependent (LDQ ≥20). In linear regression, pain intensity (β = 0.313, p < 0.001), being disabled by pain (β = 0.355, p < 0.001), borrowing pain medication (β = 0.209, p = 0.006), and emergency phone calls or clinic visits (β = 0.169, p = 0.029) were associated with degree of dependence across the range of LDQ scores. In logistic regression, pain intensity (p = 0.001) and borrowing pain medication (p = 0.004) increased the odds of severe dependence. Interviewees described how their pain influenced their pain medication use and one described pain medication addiction. Conclusion: Interventions to reduce pain intensity and pain-related disability may reduce pain medication dependence.

Factors associated with persistent opioid use after an upper extremity fracture

Aims

The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture.

Methods

A total of 734 patients recovering from an isolated upper limb fracture were recruited in this study. Opioid prescription was documented retrospectively for the period preceding the injury, and prospectively at the two- to four-week post-injury visit and six- to nine-month post-injury visit. Bivariate and multivariate analysis sought factors associated with opioid prescription from demographics, injury-specific data, Patient Reported Outcome Measurement Instrumentation System (PROMIS), Depression computer adaptive test (CAT), PROMIS Anxiety CAT, PROMIS Instrumental Support CAT, the Pain Catastrophizing Scale (PCS), the Pain Self-efficacy Questionnaire (PSEQ-2), Tampa Scale for Kinesiophobia (TSK-11), and measures that investigate levels of social support.

Results

A new prescription of opioids two to four weeks after injury was independently associated with less social support (odds ratio (OR) 0.26, p < 0.001), less instrumental support (OR 0.91, p < 0.001), and greater symptoms of anxiety (OR 1.1, p < 0.001). A new prescription of opioids six to nine months after injury was independently associated with less instrumental support (OR 0.9, p < 0.001) and greater symptoms of anxiety (OR 1.1, p < 0.001).

Conclusion

This study demonstrates that potentially modifiable psychosocial factors are associated with increased acute and chronic opioid prescriptions following upper limb fracture. Surgeons prescribing opioids for upper limb fractures should be made aware of the screening and management of emotional and social health.

Cite this article: Bone Jt Open 2021;2(2):119–124.

Association between Chronic Pain and Alterations in the Mesolimbic Dopaminergic System

Chronic pain (pain lasting for >3 months) decreases patient quality of life and even occupational abilities. It can be controlled by treatment, but often persists even after management. To properly control pain, its underlying mechanisms must be determined. This review outlines the role of the mesolimbic dopaminergic system in chronic pain. The mesolimbic system, a neural circuit, delivers dopamine from the ventral tegmental area to neural structures such as the nucleus accumbens, prefrontal cortex, anterior cingulate cortex, and amygdala. It controls executive, affective, and motivational functions. Chronic pain patients suffer from low dopamine production and delivery in this system. The volumes of structures constituting the mesolimbic system are known to be decreased in such patients. Studies on administration of dopaminergic drugs to control chronic pain, with a focus on increasing low dopamine levels in the mesolimbic system, show that it is effective in patients with Parkinson’s disease, restless legs syndrome, fibromyalgia, dry mouth syndrome, lumbar radicular pain, and chronic back pain. However, very few studies have confirmed these effects, and dopaminergic drugs are not commonly used to treat the various diseases causing chronic pain. Thus, further studies are required to determine the effectiveness of such treatment for chronic pain.

Anxiety and Osteoarthritis Disability: Updated Overview and Commentary

Introduction:

Osteoarthritis, a widespread highly painful often incapacitating joint disease continues to impose immense personal and societal challenges among adults of all ages, especially among older adults. In the absence of any effective cure or treatment, it has become essential to explore all correlates of this chronic disabling disease, especially those that might be preventable or modifiable. Anxiety, a potentially remediable state of mental distress - found linked to chronically disabling forms of arthritis, in various imperceptible ways, and which may have an immense bearing on the outcomes of osteoarthritis, has not received as much attention in the related literature as other topics, such as surgery.

Objective:

In line with previous promising work, this narrative review elected to explore the extent to which current researchers in the field are pursuing this topic, and if so, the degree to which prevailing peer-reviewed data sources support an important role for continued research in this realm, and in what regard.

Methods:

Primarily explored were the key databases housing relevant publications that emerged over Aug 1, 2018-Feb 26, 2020 using the keywords Osteoarthritis and Anxiety. Using a descriptive approach, the relative progress made over the past five previous years in this regard was assessed, in addition to what joints have been studied and with what frequency, and how the degree of interest compares to other currently researched osteoarthritis themes. The potential for intervening in the osteoarthritis pain cycle by addressing anxiety was also examined.

Results:

Findings show a high level of current interest in this topic, and that despite the paucity of prospective studies, studies on joints other than the knee and hip joints, some equivocal conclusions, small numbers of anxiety-related studies compared to other topics, and substantive design limitations, it appears that future research in this realm is strongly indicated.

Conclusion:

This topic if examined further is likely to produce highly advantageous results at all stages of the osteoarthritic disease process and in the context of primary, secondary, as well as tertiary measures to ameliorate osteoarthritis pain and disability.

Eighty years of Medication-Overuse Headache: what about Medication-Overuse Backpain?

INTRODUCTION

Although chronic low back pain (CLBP) is one of the most common pain syndromes, up to now, clear pathophysiological causes or specific treatment options are missing. Medication-overuse has been associated with chronic headache, but never with CLBP.

HYPOTHESIS

Based on several similarities between CLBP and Medication-Overuse Headache (MOH), we hypothesized that medication-overuse might contribute to CLBP as well, maybe even as an own entity. Might there be something like Medication-Overuse Backpain (MOB)?

METHODS

We substantiate our hypothesis with a preliminary case-series analyzing five patients suffering from CLBP with a marked medication-overuse. In these patients, a stepwise analgesic withdrawal was recommended.

RESULTS

Within 6 months of recruitment, five patients fulfilled the inclusion criteria and successfully completed discontinuation of their medication. All patients reported noticeable pain relief, despite the discontinuation of their analgesics. Withdrawal was well tolerated in all cases.

CONCLUSIONS

Considering our results, the described withdrawal method seems to be a simple and safe method to achieve pain reduction while simultaneously preventing organ damage. Despite the preliminary character of our results, our hypothesis might stimulate a new understanding of CLBP's pathophysiology.

Is there a relationship between self-efficacy, disability, pain and sociodemographic characteristics in chronic low back pain? A multicenter retrospective analysis

Background

Pain-related self-efficacy is defined as the beliefs held by people with chronic pain that certain activities can be carried out despite the pain. Poor self-efficacy is an obstacle to the recovery and predicts long-term disability. The aims of this study are to investigate the prevalence of poor pain self-efficacy in Italian subjects with chronic low back pain (LBP), and to inquire the relationships between self-efficacy, disability, pain, and main demographic and clinical characteristics.

Methods

A secondary multicenter retrospective analysis was done on 310 outpatients with chronic non-specific LBP. The pain self-efficacy measured with the Pain Self-Efficacy Questionnaire (PSEQ), the disability measured with the Roland & Morris Disability Questionnaire, and the pain intensity measured with the Numerical Rating Scale were considered variables to investigate, whereas demographic and clinical variables were considered predictors or potential confounders. A 40/60 PSEQ score was adopted as cut-off to distinguish between good and poor self-efficacy.

Results

199 subjects (64.2% of the sample) showed poor self-efficacy. The odds of having poor self-efficacy appeared significantly related to female gender (OR = 1.80, 95%CI [1.12;2.90]; p = 0.015) and drugs use (OR = 1.68, 95%CI [1.06;2.70]; p = 0.029). Significant relationships also emerged between disability and higher age (β = 0.07, 95%CI [0.01; 0.12]; p = 0.02), being female (β = 1.80, 95%CI [0.32;3.29]; p = 0.018), low educational level (β = − 1.68, 95%CI [− 2.59;-3.29]; p < 0.001), higher height (β = − 0.08, 95%CI [− 0.158;-0.002]; p = 0.045), pain duration [mos] (β = 0.01, 95%CI [0.001;0.021]; p = 0.041), and drugs use (β = 2.86, 95%CI [1.44;4.27]; p < 0.001). The amount of pain appeared significantly related to educational level (β = − 0.47, 95%CI [− 0.76;-0.182]; p < 0.001), smoking (β = 0.56, 95%CI [0.09; 1.03]; p = 0.021), height (β = − 0.03, 95%CI [− 0.05; − 0.002]; p = 0.036), and drugs use (β = 0.81, 95%CI [0.399;1.22]; p < 0.001). No significant correlation appeared among weight, body mass index, and referred pain neither in relation to self-efficacy, nor in relation to pain/disability.

Conclusions

The majority of our sample, composed of Italian people complained of chronic LBP, shows poor self-efficacy. Female gender and drugs use are significantly related to poor self-efficacy, low educational level negatively influences the amount of perceived pain and disability, and older age and smoking are related to disability and pain intensity, respectively. The knowledge of these sociodemographic and clinical characteristics potentially influencing chronic LBP may be useful to address more efforts towards the most negatively impacted subjects, among the entire population complained of chronic LBP.