Impact of demographic factors on chronic pain among adults in the United States

Stress, perceived competence and guilt as predictors of depression in parents with chronic pain

Introduction

Suffering from chronic pain (CP) and coping with parenthood can be challenging for parental mental health. Pain can hinder the ability to deal with demands related to parenthood, which can negatively affect their psychological well-being because of unmet caregiving expectations.

Methods

Considering the limited amount of research regarding the mental health of parents with CP, the study's main aim was to test a predictive model based on previous scientific literature, using structural equation analysis, in which parental competence and parental guilt partially mediate the relationship between parental stress and depression. To examine the moderating role of CP, the model was tested on a group of parents with CP and a control group of parents without CP. The study included 380 parents from all over Spain, of which 200 formed the group with CP and 180 participants formed the control group. A cross-sectional design was used to collect data through self-report measures.

Results

Higher levels of stress, guilt, and depression were observed in parents with CP. Based on the results, both groups of parents showed a good fit with the predictive model; parental stress was a good predictor of symptoms of depression both in parents with and without CP, parental competence mediated the relationship between parental stress and depression, being the relationship between competence and depression partially mediated by parental guilt.

Discussion

This study is the first to quantitatively examine parental competence and guilt in parents with CP, and to analyze their role as mediators between parental stress and depression in both CP and healthy parents. The results confirm previous qualitative findings and extend them to parents with CP, showing that the tested model aligns with the main theories on stress, self-efficacy, and depression, as well as existing literature on CP. These results suggest the relevance of addressing parental stress levels for reducing and preventing depressive symptoms in parents with CP and the importance of working on guilt reduction and enhancing competence in order to improve the emotional well-being of parents. The need to take into account the mental health of parents with CP to improve their quality of life is discussed.

Is the relationship between chronic pain and mortality causal? A propensity score analysis

ABSTRACT

Chronic pain is a serious and prevalent condition that can affect many facets of life. However, uncertainty remains regarding the strength of the association between chronic pain and death and whether the association is causal. We investigate the pain-mortality relationship using data from 19,971 participants aged 51+ years in the 1998 wave of the U.S. Health and Retirement Study. Propensity score matching and inverse probability weighting are combined with Cox proportional hazards models to investigate whether exposure to chronic pain (moderate or severe) has a causal effect on mortality over a 20-year follow-up period. Hazard ratios (HRs) with 95% confidence intervals (CIs) are reported. Before adjusting for confounding, we find a strong association between chronic pain and mortality (HR: 1.32, 95% CI: 1.26-1.38). After adjusting for confounding by sociodemographic and health variables using a range of propensity score methods, the estimated increase in mortality hazard caused by pain is more modest (5%-9%) and the results are often also compatible with no causal effect (95% CIs for HRs narrowly contain 1.0). This attenuation highlights the role of confounders of the pain-mortality relationship as potentially modifiable upstream risk factors for mortality. Posing the depressive symptoms variable as a mediator rather than a confounder of the pain-mortality relationship resulted in stronger evidence of a modest causal effect of pain on mortality (eg, HR: 1.08, 95% CI: 1.01-1.15). Future work is required to model exposure-confounder feedback loops and investigate the potentially cumulative causal effect of chronic pain at multiple time points on mortality.

Minimising Harm and Managing Pain: Deprescribing Opioids in Older Adults

Approximately one in three older adults (aged 65 years and over) experience pain, negatively impacting their quality of life. Opioid analgesics are commonly prescribed to manage pain; however, balancing the benefits and harms of these high-risk analgesics can be challenging for both healthcare professionals and patients. This is particularly true for older adults, as factors such as polypharmacy, age-related physiological changes and cognitive decline may impact upon opioid safety and efficacy. Deprescribing is the patient-centred process of reducing or discontinuing a medication that is no longer appropriate, or where the risks of continuation are deemed to outweigh the anticipated benefits. Opioid deprescribing has been proposed as a mechanism to reduce individual and societal opioid-related harm; however, to date, research has predominantly focused on the general adult population, rather than older adults. This current opinion aims to summarise the existing opioid deprescribing literature, discussing its applicability for older adults. Drawing on a non-systematic review of the literature, it identifies unique challenges and considerations for this population, highlights international initiatives to enhance opioid deprescribing in clinical practice and proposes future directions to advance the field.

Health Resource Utilization and Cost Impact of Integrative Medicine Services for Newly Diagnosed Chronic Pain Patients

Background: Integrative medicine (IM) is the healing-oriented practice of medicine that emphasizes the relationship between practitioner and patient. It considers the whole person, their environment, lifestyle, and social and cultural factors. It is evidence based and makes use of all appropriate therapies, conventional and complimentary. Objective: To evaluate the impact of IM services on health outcomes and care costs of chronic pain management patients compared with standard care. Methods: This article uses University of New Mexico hospital billing data from 10/2016 to 09/2019 to identify patients with nervous system or musculoskeletal pain. A total of 1,304 patients were matched using propensity scores into IM services (treatment: 652) and standard care (control: 652) cohorts for difference-in-differences analysis. The patients were matched based on age, sex, race, zip code, insurance type, ICD-10s, prescriptions, health care events, and medical claim costs. Results: Patients who used IM services had better health outcomes and lower costs at 3-month, 6-month, and 12-month follow-up. At the 12-month follow-up, the IM group showed a 19% decrease in utilization of inpatient care, a 37% decrease in Emergency Department utilization, and an 11.3% reduction in claim costs compared with the control group. Conclusion: Patients who utilize IM services as part of chronic pain management have overall lower health care costs and better health outcomes. Unfortunately, in the health system studied, less than 3% of patients utilize these services. Promotion of and education about IM services should be aimed at both patients and their providers.

Reciprocal Association Between Chronic Pain and Health Insurance Type in a Population-based Longitudinal Cohort Study

Chronic pain is a widespread condition limiting adults' daily activities and labor force participation. In the United States, withdrawal from the workforce could be associated with loss of health insurance coverage, while lack of health insurance coverage can limit access to diagnosis and management of chronic health conditions. We used a longitudinal cohort study of middle-aged adults to investigate whether chronic pain is reciprocally associated with coverage by any insurance and type of insurance coverage over a 2-year period (2018 and 2020). Among 5,137 participants (median age of 57 years in 2018), 29% reported chronic pain in either year, while 9 to 10% were uninsured each year. Using multivariable cross-lagged logistic regression analysis, chronic pain in 2018 was not associated with having any insurance coverage in 2020, and lack of coverage in 2018 was not associated with chronic pain in 2020. In further analysis, we determined that public coverage, other (non-private) coverage, or no coverage in 2018 were associated with an increased risk of chronic pain in 2020; while chronic pain in 2018 increased the risk of coverage by public rather than private insurance 2 years later, as well as the risk of coverage by other (non-private) payors. The reciprocal association of non-private insurance coverage and chronic pain may be related to insufficient access to chronic pain treatment among publicly insured adults, or qualification for public insurance based on disability among adults with chronic pain. These results demonstrate that accounting for the type of health insurance coverage is critical when predicting chronic pain in US populations. PERSPECTIVE: In a longitudinal cohort study of middle-aged US adults, the use of public and other non-private insurance predicts future experience of chronic pain, while past experience of chronic pain predicts future use of public and other non-private insurance.

Exploring Gender Differences in Veterans in a Secondary Analysis of a Randomized Controlled Trial of Mindfulness for Chronic Pain

Background

Although studies have documented higher rates of chronic pain among women Veterans compared to men Veterans, there remains a lack of comprehensive information about potential contributors to these disparities.

Materials and Methods

This study examined gender differences in chronic pain and its contributors among 419 men and 392 women Veterans, enrolled in a mindfulness trial for chronic pain. We conducted descriptive analyses summarizing distributions of baseline measures, obtained by survey and through the electronic health record. Comparisons between genders were conducted using chi-square tests for categorical variables and t-tests for continuous measures.

Results

Compared to men, women Veterans were more likely to have chronic overlapping pain conditions and had higher levels of pain interference and intensity. Women had higher prevalence of psychiatric and sleep disorder diagnoses, greater levels of depression, anxiety, post-traumatic stress disorder, fatigue, sleep disturbance, stress and pain catastrophizing, and lower levels of pain self-efficacy and participation in social roles and activities. However, women were less likely to smoke or have a substance abuse disorder and used more nonpharmacological pain treatment modalities.

Conclusion

Among Veterans seeking treatment for chronic pain, women differed from men in their type of pain, had greater pain intensity and interference, and had greater prevalence and higher levels of many known biopsychosocial contributors to pain. Results point to the need for pain treatment that addresses the comprehensive needs of women Veterans.

Clinical Trial Registration Number: NCT04526158. Patient enrollment began on December 4, 2020.

Overview and Feasibility of a Novel Transdisciplinary Integrative Approach to High Impact Chronic Pain in Vermont

Background/Objective

Pain is one of the most common chronic conditions in the US, estimated to affect 20.9% of the population (51.6 million people). We evaluated the Partners Aligned in Transformative Healing (PATH) program at University Medical Center's Comprehensive Pain Program clinic. Feasibility, initial clinical and financial results were assessed to inform payers' support for PATH, an integrative transdisciplinary program within a bundled payment format.

Methods

Participants completed a multi-week program including integrative therapies, with empirically validated assessment surveys administered at the beginning and end of the program. Insurance claims data were analyzed 12 months pre- and post-program. Statistical significance of pre-post differences was assessed by paired T-tests with P < 0.05.

Results

Between June 2019 and August 2022, 170 individuals enrolled in PATH, 151 (88.8%) completed the program, and 121 participants completed outcome surveys. Participants were predominately White, non-Hispanic (98%), female (76%), with an average age of 49.8. All participant-reported clinical outcomes (PROs) showed statistically significant improvement from baseline to final assessment, and some but not all were clinically significant. PEG subscale of average pain interference, enjoyment of life, and interference with general activity each decreased. The T-scores for the following domains of PROMIS-29 decreased: Pain interference; fatigue; sleep disturbance; anxiety, and depression. The PROMIS-29 domains of overall physical function and social roles and activities mean T-scores increased. Per Member Per Month (PMPM) total cost of care decreased by $462 (18%). Emergency room utilization for all diagnoses decreased by 457 visits/1000 patients (65%), and for pain-related diagnoses by 194 visits/1000 patients (67%) during the observation period.

Conclusions

Results suggest that the PATH Program is a feasible and acceptable model that shows initial effectiveness relative to short-term patient-reported clinical outcomes and shows signs of durability in both utilization and financial outcomes at 1 year. The results support continued study including a multi-site RCT.

Greater socioenvironmental risk factors and higher chronic pain stage are associated with thinner bilateral temporal lobes

INTRODUCTION

Previous research indicates ethnic/race group differences in pain and neurodegenerative diseases. Accounting for socioenvironmental factors reduces ethnic/race group differences in clinical and experimental pain. In the current study sample, we previously reported that in individuals with knee pain, ethnic/race group differences were observed in bilateral temporal lobe thickness, areas of the brain associated with risk for Alzheimer's disease, and related dementias. The purpose of the study was to determine if socioenvironmental factors reduce or account for previously observed ethnic/race group differences and explore if a combined effect of socioenvironmental risk and chronic pain severity on temporal lobe cortices is evident.

METHODS

Consistent with the prior study, the sample was comprised of 147 adults (95 women, 52 men), 45-85 years of age, who self-identified as non-Hispanic Black (n = 72) and non-Hispanic White (n = 75), with knee pain with/at risk for osteoarthritis. Measures included demographics, health history, pain questionnaires, cognitive screening, body mass index, individual- and community-level socioenvironmental factors (education, income, household size, marital and insurance status, and area deprivation index), and brain imaging. We computed a summative socioenvironmental risk index.

RESULTS

Regression analyses showed that with the inclusion of socioenvironmental factors, the model was significant (p < .001), and sociodemographic (ethnic/race) group differences were not significant (p = .118). Additionally, findings revealed an additive stress load pattern indicating thinner temporal lobe cortices with greater socioenvironmental risk and chronic pain severity (p = .048).

IMPLICATIONS

Although individual socioenvironmental factors were not independent predictors, when collectively combined in models, ethnic/race group differences in bilateral temporal lobe structures were not replicated. Further, combined socioenvironmental risk factors and higher chronic pain severity were associated with thinner bilateral temporal lobes.

Elucidating factors contributing to disparities in pain-related experiences among adults with or at risk for knee osteoarthritis

Background and purpose

We and others have reported ethnic/race group differences in clinical pain, physical function, and experimental pain sensitivity. However, recent research indicates that with consideration for socioenvironmental factors, ethnicity/race differences become less or non-significant. Understanding of factors contributing to pain inequities are needed. Guided by the NIA and NIMHD Health Disparities Research Frameworks, we evaluate the contributions of environmental and behavioral factors on previously reported ethnic/race group differences in: (1) clinical pain, (2) physical function, and (3) experimental pain in individuals with knee pain.

Methods

Baseline data from Understanding of Pain and Limitations in Osteoarthritis Disease (UPLOAD) and UPLOAD-2 studies were analyzed. Participants were adults 45 to 85 years old who self-reported as non-Hispanic white (NHW) or black (NHB) with knee pain. A health assessment and quantitative sensory testing were completed. Sociodemographics, environmental, health, clinical and experimental pain, and physical functioning measures were included in nested regressions.

Results

Pooled data from 468 individuals, 57 ± 8 years of age, 63% women, and 53% NHB adults. As NHB adults were younger and reported greater socioenvironmental risk than the NHW adults, the term sociodemographic groups is used. With inclusion of recognized environmental and behavioral variables, sociodemographic groups remained a significant predictor accounting for <5% of the variance in clinical pain and physical function and <10% of variance in experimental pain.

Conclusion

The incorporation of environmental and behavioral factors reduced relationships between sociodemographic groups and pain-related outcomes. Pain sites, BMI, and income were significant predictors across multiple models. The current study adds to a body of research on the complex array of factors contributing to disparities in pain-related outcomes.