Cost Burden of Chronic Pain Patients in a Large Integrated Delivery System in the United States

Pain, comorbidities, and clinical decision-making: conceptualization, development, and pilot testing of the Pain in Aging, Educational Assessment of Need instrument

Introduction

Pain is highly prevalent in older adults and often contextualized by multiple clinical conditions (pain comorbidities). Pain comorbidities increase with age and this makes clinical decisions more complex. To address gaps in clinical training and geriatric pain management, we established the Pain in Aging-Educational Assessment of Need (PAEAN) project to appraise the impacts of medical and mental health conditions on clinical decision-making regarding older adults with pain. We here report development and pilot testing of the PAEAN survey instrument to assess clinician perspectives.

Methods

Mixed-methods approaches were used. Scoping review methodology was applied to appraise both research literature and selected Medicare-based data. A geographically and professionally diverse interprofessional advisory panel of experts in pain research, medical education, and geriatrics was formed to advise development of the list of pain comorbidities potentially impacting healthcare professional clinical decision-making. A survey instrument was developed, and pilot tested by diverse licensed healthcare practitioners from 2 institutions. Respondents were asked to rate agreement regarding clinical decision-making impact using a 5-point Likert scale. Items were scored for percent agreement.

Results

Scoping reviews indicated that pain conditions and comorbidities are prevalent in older adults but not universally recognized. We found no research literature directly guiding pain educators in designing pain education modules that mirror older adult clinical complexity. The interprofessional advisory panel identified 26 common clinical conditions for inclusion in the pilot PAEAN instrument. Conditions fell into three main categories: "major medical", i.e., cardio-vascular-pulmonary; metabolic; and neuropsychiatric/age-related. The instrument was pilot tested by surveying clinically active healthcare providers, e.g., physicians, nurse practitioners, who all responded completely. Median survey completion time was less than 3 min.

Conclusion

This study, developing and pilot testing our "Pain in Aging-Educational Assessment of Need" (PAEAN) instrument, suggests that 1) many clinical conditions impact pain clinical decision-making, and 2) surveying healthcare practitioners about the impact of pain comorbidities on clinical decision-making for older adults is highly feasible. Given the challenges intrinsic to safe and effective clinical care of older adults with pain, and attendant risks, together with the paucity of existing relevant work, much more education and research are needed.

Does competition support integrated care to improve quality?

Introduction

This work investigates the compatibility of integrated care and competition in China and analyses the impact of integrated care on regional care quality (DeptQ) within a competitive framework.

Method

The study was built on multivariate correspondence analysis and a two-way fixed-effects model. The data were collected from Xiamen's Big Data Application Open Platform and represent nine specialised departments that regularly performed inter-institutional referrals between 2016 and 2019.

Results

First, care quality for referred patients (ReferQ) and the relative scale of referred patients (ReferScale) and competition have an antagonistic but not completely mutually exclusive relationship. Second, ReferQ and competition both have a significant effect on DeptQ, but only when competition is weak can ReferQ and competition act synergistically on DeptQ. When competition is fierce, competition will weaken the impact of ReferQ on DeptQ.

Conclusion

Changes in the intensity of integrated care and competition ultimately affect care quality.

Transrectal osteopathic manipulation treatment for chronic coccydynia: feasibility, acceptability and patient-oriented outcomes in a quality improvement project

CONTEXT

Pain of the coccyx, coccydynia, is a common condition with a substantial impact on the quality of life. Although most cases resolve with conservative care, 10 % become chronic and are more debilitating. Treatment for chronic coccydynia is limited; surgery is not definitive. Osteopathic manipulative treatment (OMT) is the application of manually guided forces to areas of somatic dysfunction to improve physiologic function and support homeostasis including for coccydynia, but its use as a transrectal procedure for coccydynia in a primary care clinic setting is not well documented.

OBJECTIVES

We aimed to conduct a quality improvement (QI) study to explore the feasibility, acceptability, and clinical effects of transrectal OMT for chronic coccydynia in a primary care setting.

METHODS

This QI project prospectively treated and assessed 16 patients with chronic coccydynia in a primary care outpatient clinic. The intervention was transrectal OMT as typically practiced in our clinic, and included myofascial release and balanced ligamentous tension in combination with active patient movement of the head and neck. The outcome measures included: acceptance, as assessed by the response rate (yes/no) to utilize OMT for coccydynia; acceptability, as assessed by satisfaction with treatment; and coccygeal pain, as assessed by self-report on a 0-10 numerical rating scale (NRS) for coccydynia while lying down, seated, standing, and walking.

RESULTS

Sixteen consecutive patients with coccydynia were offered and accepted OMT; six patients also received other procedural care. Ten patients (two males, eight females) received only OMT intervention for their coccydynia and were included in the per-protocol analysis. Posttreatment scores immediately after one procedure (acute model) and in follow-up were significantly improved compared with pretreatment scores. Follow-up pain scores provided by five of the 10 patients demonstrated significant improvement. The study supports transrectal OMT as a feasible and acceptable treatment option for coccydynia. Patients were satisfied with the procedure and reported improvement. There were no side effects or adverse events.

CONCLUSIONS

These data suggest that the use of transrectal OMT for chronic coccydynia is feasible and acceptable; self-reported improvement suggests utility in this clinic setting. Further evaluation in controlled studies is warranted.

Effect of an online posture exercise program during the COVID-19 pandemic on students' musculoskeletal pain and quality of life

BACKGROUND

Prolonged sitting and poor posture can contribute to musculoskeletal pain and have a negative effect on health-related quality of life (HRQoL) among young adults. Any prolonged posture leads to static loading of soft tissues and causes discomfort. Seated posture leads to inactivity causing an accumulation of metabolites, accelerating disk degeneration and musculoskeletal pain. Regular exercise has major contributions to the prevention and treatment of some health problems such as musculoskeletal disorders.

OBJECTIVE

This study aimed to assess the impact of online posture exercises on musculoskeletal pain and health related quality of life among university students receiving distance education during the COVID-19 pandemic.

METHODS

This randomized controlled trial involved 72 students divided into intervention (n= 35) and control (n= 37) groups. The intervention group followed an 8-week online stretching and posture exercise program. Baseline and 8-week results were measured using the SF-36 QoL Questionnaire and Cornell Musculoskeletal Discomfort Questionnaire (CMDQ).

RESULTS

Students spent an average of 5.4 ± 2.5 hours daily at computers. While there was no difference between the scores of any region in the CMDQ in the control group, there was a decrease in the neck, right shoulder, left shoulder, waist, left upper leg, right lower leg, and left lower leg discomfort scores in the intervention group (p< 0.05). There was a significant difference between the intervention and control groups in the total score of SF-36 and the sub-dimensions of vitality and mental health (p< 0.05).

CONCLUSION

The online posture exercise program led to notable reductions in musculoskeletal pain and improvements in QoL among university students. Examining the effectiveness of online exercise programs in different age groups is important for health benefits during quarantines.

Heart rate variability in adults with chronic musculoskeletal pain: A systematic review

PURPOSE

The aim of this review was to compare the heart rate variability (HRV) responses at rest of adults with chronic musculoskeletal pain against healthy controls.

METHODS

The PubMed, Scopus, Web of Science (Science and Social Science Citation Index), and CINAHL databases were searched, with no date restrictions. Two independent reviewers selected observational studies that characterized the HRV responses at rest in adults with chronic musculoskeletal pain compared with those of healthy controls. Methodological quality was assessed using the Downs and Black checklist.

RESULTS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. HRV in adults with chronic musculoskeletal pain was evaluated systematically. Of the 4893 studies screened, 20 of poor-to-moderate quality met the inclusion criteria. Most studies used electrocardiography and at least one time and/or frequency domain index. Studies were found that investigated HRV in adults with temporomandibular disorders, neck pain, whiplash, low back pain, and fibromyalgia. The heterogeneity of the studies in relation to painful conditions, parameters or position for HRV analysis precluded a meta-analysis. In general, these studies seem to show increased sympathetic and decreased parasympathetic modulation in adults with musculoskeletal pain when compared to controls.

CONCLUSIONS

Adults with musculoskeletal pain exhibited a decline in HRV compared to controls. However, definitive conclusions cannot be drawn since the evidence is heterogeneous and of moderate quality. Further high-quality research with standardized measurements is needed.

Emotional Awareness and Expression Interview: Examining Interview Content and Patient Experiences in Two Medical Samples

A single session of Emotional Awareness and Expression Therapy (EAET)-the EAET Interview-was previously shown to lead to clinical benefits for patients with centralized somatic conditions in primary care (Ziadni et al. in Health Psychol 37(3):282-290, 2018) and tertiary care (Carty et al. in Pain Med 20(7):1321-1329, 2019) settings. There has yet to be an examination of patients' experiences of and reactions to the EAET Interview, which is crucial in evaluating possible clinical implementation of the interview. We conducted secondary analyses on 88 patients (M age = 41.32, 90.9% women) from the two prior trials (primary care N = 51; tertiary care N = 37). Analyses examined interview processes (stress disclosure themes, working alliance, and emotional processing) and patients' reactions to the interview (interview credibility and perceived value of the interview), comparing the two samples and examining correlations among these variables. All patients disclosed at least one stressful life experience, commonly interpersonal problems (89.2%) and childhood adversity (51.5%). Patients had moderately high levels of working alliance and emotional processing during the interview and reported high interview credibility and perceived value of the interview. More extensive emotional processing of stressors was associated with more positive patient reactions to the interview, including higher interview credibility (r = .23) and perceived value (r = .32). We conclude that the single-session EAET Interview was valued by most patients, and patients' emotional processing is particularly beneficial. Addressing the trauma and emotional conflicts of patients with centralized somatic conditions is both feasible and valuable in front-line medical settings.

The invisible cost of pain management by the current International Classification of Diseases coding system: a study in a tertiary care inpatient setting

ABSTRACT

The International Classification of Diseases ( ICD ) is applied worldwide for public health data collection among other use cases. However, the current version of the ICD ( ICD-10 ), to which the reimbursement system is linked in many countries, does not represent chronic pain properly. This study aims to compare the ICD-10 with the ICD-11 in hospitalized patients in terms of specificity, clinical utility, and reimbursement for pain management. The medical records of hospitalized patients consulted for pain management at Siriraj Hospital, Thailand, were reviewed, and all pain-related diagnoses were coded into ICD-10 and ICD-11 . The data of 397 patients showed unspecified pain was coded 78% in the ICD-10 and only 0.5% in the ICD-11 version. The difference gap in the proportion of unspecified pain between the 2 versions is wider than in the outpatient setting. The 3 most common codes for ICD-10 were other chronic pain, low back pain, and pain in limb. The 3 most common codes for ICD-11 were chronic cancer pain, chronic peripheral neuropathic pain, and chronic secondary musculoskeletal pain. As in many other countries, no pain-related ICD-10 codes were coded for routine reimbursement. The simulated reimbursement fee remained the same when adding 397 pain-related codings, even if the cost of pain management, such as cost of labor, existed. Compared with the ICD-10 version, the ICD-11 is more specific and makes pain diagnoses more visible. Thus, shifting from ICD-10 to ICD-11 has the potential to improve both the quality of care and the reimbursement for pain management.

Impact of Electronic Chronic Pain Questions on patient-reported outcomes and healthcare utilization, and attitudes toward eCPQ use among patients and physicians: prospective pragmatic study in a US general practice setting

Objective

The Electronic Chronic Pain Questions (eCPQ) has been developed to help healthcare providers systematically capture chronic pain data. This study evaluated the impact of using the eCPQ on patient-reported outcomes (PROs) and healthcare resource utilization (HCRU) in a primary care setting, and patient and physician perceptions regarding use of, and satisfaction with, the eCPQ.

Methods

This was a prospective pragmatic study conducted at the Internal Medicine clinic within the Henry Ford Health (HFH) Detroit campus between June 2017 and April 2020. Patients (aged ≥18 years) attending the clinic for chronic pain were allocated to an Intervention Group to complete the eCPQ in addition to regular care, or a control group to receive regular care only. The Patient Health Questionnaire-2 and a Patient Global Assessment were assessed at baseline, 6-months, and 12-months study visits. HCRU data were extracted from the HFH database. Telephone qualitative interviews were conducted with randomly selected patients and physicians who used the eCPQ.

Results

Two hundred patients were enrolled, 79 in each treatment group completed all 3 study visits. No significant differences (p > 0.05) were found in PROs and HCRU between the 2 groups. In qualitative interviews, physicians and patients reported the eCPQ as useful, and using the eCPQ improved patient-clinician interactions.

Conclusion

Adding the eCPQ to regular care for patients with chronic pain did not significantly impact the PROs assessed in this study. However, qualitative interviews suggested that the eCPQ was a well-accepted and potentially useful tool from a patient and physician perspective. By using the eCPQ, patients were better prepared when they attended a primary care visit for their chronic pain and the quality of patient-physician communication was increased.

The efficacy of acceptance and commitment therapy for chronic pain: A three-level meta-analysis and a trial sequential analysis of randomized controlled trials

The current study included randomized controlled trials (RCTs) to assess the benefits of Acceptance and commitment therapy (ACT) for chronic pain. Searches were conducted in Web of Science, PsycINFO, PubMed, Scopus, Cochrane Library, and Embase from inception until September 30, 2022. Thirty-three RCTs, including 2293 participants, were included. Small to medium effect sizes for pain intensity/physical function favoring ACT were found both at post-treatment (pain intensity: g = 0.44; physical function: g = 0.59) and follow-up (pain intensity: g = 0.34; physical function: g = 0.56). The effect sizes on psychological outcomes were significant at post-treatment (depression: g = 0.43; anxiety: g = 0.43; quality of life: g = 0.45) and follow-up (depression: g = 0.43; anxiety: g = 0.35; quality of life: g = 0.43). The results of the trial sequential analyses indicated that pooled estimates were unlikely to be incidental findings, as effects of multiple testing were controlled and power was adequate. Face-to-face ACT yielded significantly larger effects on physical outcomes than internet-delivered ACT. Participants with chronic headache and fibromyalgia showed greater benefit from ACT compared to those with non-specific pain or mixed pain. In addition, the longer the follow-up duration, the smaller the effect sizes for pain intensity/physical function at follow-up. The present meta-analysis suggests sufficient evidence for the significant benefits of ACT for people with chronic pain.

A Linear Decomposition Approach to Explain Excess Direct Healthcare Expenditures Associated with Pain Among Adults with Osteoarthritis

Objective:

Many patients with osteoarthritis experience pain which can lead to higher healthcare expenditures. It is important to understand the factors that drive the excess expenditures associated with pain in osteoarthritis.

Design:

Cross-sectional.

Study sample:

Our study sample consisted of adults (age ⩾ 18 years) from the Medical Expenditure Panel Survey (MEPS, 2018).

Methods:

Adults who were alive during the calendar year and had pain status were included in this study (N = 2804 weighted N = 32.03 million). Osteoarthritis was identified from the medical conditions file and household file. We used multivariable ordinary least squares regression to identify the statistically significant association of pain with direct healthcare expenditures. The Blinder-Oaxaca post-linear decomposition on log-transformed total direct healthcare expenditures was used to estimate the extent to which differences in characteristics contribute to the excess expenditures associated with pain.

Results:

Adults with osteoarthritis and pain had higher average expenditures ($21 814 vs $10 827, P < .001; 9.318 vs 8.538 in logtransformed expenditures) compared to those without pain. Pooled regression weights explained 62.9% of excess expenditures differences in characteristics between the 2 groups. The 2 main drivers of excess healthcare expenditures among adults with osteoarthritis and pain were (i) comorbidities (diabetes, asthma, chronic obstructive pulmonary disease, depression, heart diseases, cancer, and non-cancer pain conditions and (ii) prescription medications (NSAIDs, opioids, and polypharmacy).

Conclusion:

Need factors such as comorbid conditions, and prescription treatment explained the excess healthcare expenditures among adults with osteoarthritis and pain. The study findings suggest that reducing polypharmacy and appropriate management of comorbid conditions may be a pathway to reduce excess expenditures among adults with osteoarthritis and pain.

Recurrent abdominal pain visits to the emergency department: A case report using the Central Sensitization Inventory

Chronic pain conditions are among the most common complaints seen in the emergency department (ED). Exacerbations of these conditions are often approached as one would an acute painful condition, with liberal use of imaging, labs, and analgesics. This patient population is often prescribed short courses of opioids without a definite explanation for their painful episodes and often leave the ED dissatisfied with their experience. We describe a patient with a history of chronic abdominal pain who presented to the ED with an exacerbation of his pain. Upon further review of his previous records, we noted that this patient experienced many similar events, resulting in 46 imaging studies over the past year. At this point, the patient was given the Central Sensitization Inventory, and his score demonstrated severe underlying central sensitization. The patient was counseled about his condition and provided with appropriate follow-up care.

Older Female Farmers and Modeling of Occupational Hazards, Wellbeing, and Sleep-Related Problems on Musculoskeletal Pains

Musculoskeletal pains seem to be the most prevalent among occupational diseases in older female farmers. This study analyzes the relationships between exposure to ergonomic or environmental hazards, sleep-related problems, wellbeing, and musculoskeletal pains in older female farmers. In this study, older farmer means a farmer aged ≥60, and 2005 older female farmers were selected. A structural equation model (SEM) was used to investigate the relationships. In the results of SEM, musculoskeletal pains were more affected by the level of wellbeing (standardized path coefficient = −0.149) than the level of sleep-related problems (standardized path coefficient = 0.131) or the exposure level of ergonomic hazards (standardized path coefficient = 0.086). Among the ergonomic risk factors felt by elderly female farmers, the influence level of “awkward posture” (0.735), “repetitive motion” (0.718), or “standing posture” (0.693) was greater than that of “manual material handling” (0.661). “Vibration” (0.786) and “noise” (0.683) were influential variables of environmental hazards. In addition, “upper limb pain” (0.796) and “lower limb pain” (0.751) variables were more influential variables of musculoskeletal pains than the “backache” (0.472) variable. This study shows that strategies to improve wellbeing or sleep problems are important to alleviate or prevent musculoskeletal pains among older female farmers.

Dorsal Column Stimulation and Cannabinoids in the Treatment of Chronic Nociceptive and Neuropathic Pain: a Review of the Clinical and Pre-clinical Data

PURPOSE OF REVIEW

The main objective of this review is to appraise the literature on the role of spinal cord stimulation (SCS), cannabinoid therapy, as well as SCS and cannabinoid combination therapy for the management of chronic neuropathic and nociceptive pain. Current research suggests that SCS reduces pain and increases functional status in carefully selected patients with minimal side effects.

RECENT FINDINGS

As cannabinoid-based medications become a topic of increasing interest in pain management, data remains limited regarding the clinical efficacy of cannabinoids for pain relief. Furthermore, from a mechanistic perspective, although various pain treatment modalities utilize overlapping pain-signaling pathways, clarifying whether cannabinoids work synergistically with SCS via shared mechanisms remains to be determined. In considering secondary outcomes, the current literature suggests cannabinoids improve quality of life, specifically sleep quality, and that SCS decreases opioid consumption, increases functional capacity, and decreases long-term healthcare costs. These findings, along with the high safety profiles of SCS and cannabinoids overall, incentivize further exploration of cannabinoids as an adjunctive therapy to SCS in the treatment of neuropathic and nociceptive pain.

Effect of perioperative cognitive behavioural therapy on chronic post-surgical pain among breast cancer patients with high pain catastrophising characteristics: protocol for a double-blinded randomised controlled trial

BACKGROUND

Surgery is regarded as the primary treatment for breast cancer. Chronic post-surgical pain (CPSP) is a recognised complication after breast cancer surgery, and it is estimated to affect 20-30% of women. Pain catastrophizing has emerged as one of the most influential psychological variables associated with CPSP.

METHODS

This trial will be a single-centre, prospective, double-blinded, superiority, randomised controlled trial (RCT). Patients scheduled for elective breast cancer surgery (wide local excision or mastectomy with or without axillary lymph node dissection) will be screened preoperatively for high pain catastrophising. Patients with high pain catastrophising, defined as a score of ≥ 24 on the Pain Catastrophising Scale will be deemed eligible for inclusion in the study. Participants will be randomly assigned to receive either a cognitive behavioural therapy or an educational mindfulness based programme during their perioperative period. The primary outcome is the Brief Pain Inventory short form average pain severity score at 3 months postoperatively. Secondary outcomes include patient-reported quality of recovery at days 1-2 after surgery, levels of pain catastrophising, reported depressed mood and anxiety.

DISCUSSION

To the best of our knowledge, this protocol describes the first RCT which directly examines the effect of perioperative cognitive behavioural therapy on CPSP among breast cancer patients with high pain catastrophising characteristics. The outcomes of this trial may have significant implications for these patients because perioperative cognitive behavioural therapy has the potential to become an important perioperative intervention to complement patient management.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04924010 . Registered on 11 June 2021. All item from the World Health Organisation Trial Registration Data set have been included.

Mindfulness-based therapy compared to cognitive behavioral therapy for opioid-treated chronic low back pain: Protocol for a pragmatic randomized controlled trial

OBJECTIVE

Chronic low back pain (CLBP) is disabling and costly. Existing therapies have proven suboptimal, with many patients resorting to long-term opioid therapy, which can cause harms. Cognitive behavioral (CBT) and mindfulness-based (MBT) therapies can be effective and offer unique skills for safe pain coping. This article describes the protocol for a study evaluating comparative effectiveness of CBT and MBT in adults with opioid-treated CLBP.

DESIGN

Pragmatic, multi-center randomized controlled trial (RCT).

SETTINGS

Community and outpatient care.

PARTICIPANTS

Planned enrollment of 766 adults (383/group) with CLBP treated with long-term opioids (≥3 months; ≥15 mg/day morphine-equivalent dose).

INTERVENTIONS

CBT or MBT consisting of eight weekly therapist-led, two-hour group sessions, and home practice (≥30 min/day, 6 days/week) during the 12-month study.

MAIN OUTCOME MEASURES

Main outcome measures, collected by self-report at baseline, then three, six, nine and 12 months post-entry, include co-primary measures: pain intensity (Numeric Rating Scale) and function (Oswestry Disability Index), and secondary measures: quality of life (Medical Outcomes Study) and average daily opioid dose (Timeline Followback). Baseline scores of depression, anxiety, and opioid misuse questionnaires will be assessed as potential contributors to the heterogeneity of treatment response. Intention-to-treat, linear mixed-effects analysis will examine treatment effectiveness. Qualitative data will augment the quantitative measures.

CONCLUSIONS

This will be the largest RCT comparing CBT and MBT in opioid-treated CLBP. It will provide evidence on the impact of these interventions, informing clinical decisions about optimal therapy for safe, effective care, improving quality of life and decreasing opioid-related harm among adults with refractory CLBP.

The Greek Neuropathic Pain Registry: The structure and objectives of the sole NPR in Greece

OBJECTIVES

Neuropathic pain (NP) is a complex condition that impairs the patients' quality of life. Registries are useful tools, increasingly used as they provide high-quality data. This article aims to describe the Greek Neuropathic Pain Registry (Gr.NP.R.) design, the patients' baseline data, and real-world treatment outcomes.

METHODS

The Gr.NP.R. collects electronically, stores, and shares real-world clinical data from Pain and Palliative Care centers in Greece. It is a web-based application, which ensures security, simplicity, and transparency. VAS, DN4, and Pain Detect were used for pain and NP assessment.

RESULTS

From 2016 to 2020, 5980 patients with chronic pain, of cancer or non-cancer origin, were examined and 2334 fulfilled the NP inclusion criteria (VAS > 5, DN4 > 4, and Pain Detect ≥ 19). At the first visit, the mean age was 64.8 years, 65.5% were female patients, and 97.9% were Greek. The mean (SD) time from pain initiation to visiting the pain clinics was 1.5 (3.8) years. Most patients were undertreated. Following the patients' registration, the national guidelines were implemented. The majority of the prescribed medications were gabapentinoids (70.2%), especially pregabalin (62.6%), and opioids (tramadol, 55.3%). At visits 1 and 6, mean VAS was 7.1 and 5, and mean DN4 score was 5.6 and 3.5, respectively.

CONCLUSIONS

The Gr.NP.R. provides information on the demographics, clinical progress, treatment history, treatment responses, and the drugs of choice for patients with cancer and non-cancer NP. The collected data may help physicians plan the management of their patients.

Is Buprenorphine Effective for Chronic Pain? A Systematic Review and Meta-analysis

OBJECTIVE

The objective was to perform a systematic review and meta-analysis of the literature on the effects of buprenorphine on chronic pain outcomes (i.e., patient-reported pain intensity) in patients with and without opioid use disorder (OUD).

DESIGN

Ovid/Medline, PubMed, Embase, and the Cochrane Library were searched for studies that explored the effectiveness (in reducing pain) of buprenorphine treatment for chronic pain patients with and without a history of OUD. Randomized controlled trials and observational studies were included in the review.

METHODS

Two separate searches were conducted to identify buprenorphine trials that included chronic pain patients either with or without OUD. Five studies used validated pain report measures and included a chronic pain population with OUD. Nine studies used validated report measures and included chronic pain patients without OUD. Meta-analysis was performed using the R, version 3.2.2, Metafor package, version 1.9-7.

RESULTS

The meta-analysis revealed that buprenorphine has a beneficial effect on pain intensity overall, with a small mean effect size in patients with comorbid chronic pain and OUD and a moderate- to large-sized effect in chronic pain patients without OUD.

CONCLUSIONS

Our results indicate that buprenorphine is modestly beneficial in reducing pain intensity in patients without OUD. Although informative, these findings should be carefully interpreted due to the small amount of data available and the variation in study designs.

Musculoskeletal Pain and Teleworking in Times of the COVID-19: Analysis of the Impact on the Workers at Two Spanish Universities

The special situation brought about by the coronavirus pandemic and the confinement imposed by the Government, has given rise to numerous changes in working habits. The workers at the universities have had to start a period of teleworking that could give rise to consequences for the musculoskeletal system. The objective of this article is to analyze the impact of the confinement on the musculoskeletal health of the staff of two Spanish universities. A cross-sectional, observational study was carried out on the workers. Data was taken in April-May 2020 and included: The Standardized Kuorinka Modified Nordic Questionnaire, the Perceived Stress Scale and another one on sociodemographic data. This study comprised 472 people. The areas of pain noted during the confinement period concluded that it was less in all cases (p < 0.001). The frequency of physical activity carried out increased significantly during the period of confinement (p < 0.04), especially in women. The type of physical activity done was also seen to modify during this period (p < 0.001), with a preference for strength training and stretching exercises. In conclusion, the confinement gave rise to changes in the lifestyle and in the musculoskeletal pain of the workers at the universities. All of this must be taken into account by health institutions and those responsible for the Prevention of Occupational Risks at Spanish universities.

Relationship Between Opioid Analgesic Prescription and Unemployment in Patients Seeking Acupuncture for Chronic Pain in Urban Primary Care

OBJECTIVE

The widespread use of opioid analgesics to treat chronic nonmalignant pain has contributed to the ongoing epidemic of opioid-related morbidity and mortality. Previous studies have also demonstrated a relationship between opioid analgesic use and unemployment due to disability. These studies have been limited to mainly white European and North American populations. The objective of this study is to explore the relationship between opioid analgesic use for chronic nonmalignant pain in an urban, mainly black and Hispanic, low-income population.

DESIGN

This is a cross-sectional observational study.

SETTING

Subjects were recruited from six urban primary care health centers.

SUBJECTS

Adults with chronic neck, back, or osteoarthritis pain participating in an acupuncture trial were included.

METHODS

Survey data were collected as a part of the Acupuncture Approaches to Decrease Disparities in Pain Treatment two-arm (AADDOPT-2) comparative effectiveness trial. Participants completed a baseline survey including employment status, opioid analgesic use, the Brief Pain Inventory, the global Patient Reported Outcomes Measurement Information Systems quality of life measure, the Patient Health Questionnaire-9 (PHQ-9), and demographic information. A multivariable logistic regression model was built to examine the association between opioid analgesic use and unemployment.

RESULTS

Opioid analgesic use was associated with three times the odds of unemployment due to disability while controlling for potential confounders, including depression, pain severity, pain interference, global physical and mental functioning, and demographic characteristics.

CONCLUSIONS

This study adds to the growing body of evidence that opioid analgesics should be used with caution in chronic nonmalignant pain.

Evaluation of the efficacy of an internet-based pain education and exercise program for chronic musculoskeletal pain in comparison with online self-management booklet: a protocol of a randomised controlled trial with assessor-blinded, 12-month follow-up, and economic evaluation

BACKGROUND

Chronic musculoskeletal pain is one of the main causes of years lived with disability and generates the highest cost of health care among chronic pain conditions. Internet-based treatments have been shown to be an alternative for the treatment of musculoskeletal conditions, in addition to reducing barriers such as travel, high demands on the public health system, lack of time, lack of insurance coverage for private care, and high costs for long-term treatment. The aim of this clinical trial is to develop and test the effectiveness and cost-effectiveness of, an internet-based self-management program based on pain education and exercise for people with chronic musculoskeletal pain.

METHODS

This is a prospectively registered, assessor-blinded, two-arm randomised controlled trial with economic evaluation comparing the Internet-based pain education and exercise intervention with a control group that will receive an online booklet. One hundred and sixty patients will be recruited from Sao Paulo, Brazil. Follow-ups will be conducted in post-treatment, 6 and 12 months after randomisation. The conduct of the study, as well as the evaluations and follow-ups will be carried out entirely remotely, through online platforms and telephone calls. The primary outcome will be pain intensity at post-treatment (8 weeks) measured using the 11-item Pain Numerical Rating Scale. Secondary outcomes will be biopsychosocial factors presents in the chronic musculoskeletal pain condition. Costs due to chronic musculoskeletal pain will be also measured, and cost-effectiveness analysis from a societal perspective will performed.

DISCUSSION

Our hypothesis is that internet-based pain education and exercise will be better than an online booklet in reducing pain and improving biopsychosocial outcomes in patients with chronic musculoskeletal pain. In addition, we believe that there will be good acceptance of patients for the internet-based intervention and that internet-based intervention will be more cost effective than the online booklet.

TRIAL REGISTRATION

The study was prospectively registered at ClinicalTrials.gov ( NCT04274439 , registered 18 February 2020).

Low-Intensity Continuous Ultrasound for the Symptomatic Treatment of Upper Shoulder and Neck Pain: A Randomized, Double-Blind Placebo-Controlled Clinical Trial

Purpose

Low-intensity continuous ultrasound (LICUS) is an emerging high-dosimetry ultrasound-based therapy for accelerated tissue healing and the treatment of myofascial pain. In this study, LICUS treatment is clinically evaluated for chronic upper neck and shoulder pain in a randomized, multi-site, double-blind, placebo-controlled study.

Patients and Methods

CONSORT guidelines were followed in conducting and reporting the clinical trial. Thirty-three participants with upper trapezius myofascial pain were randomized for treatment with active (n=25) or placebo (n=8) devices. Investigators and subjects were blinded to treatment groups. Participants self-reported pain daily, rating from 0–10 on the numeric rating scale. If pain rating was more significant than or equal to 3, the LICUS (3MHz, 0.132W/cm², 1.3W, 4 hours) was self-applied for total energy dosimetry of 18,720 Joules per treatment. During the 4-week study, daily pain rating was recorded. If LICUS treatment was delivered, pain before, during, and after treatment were recorded as well as the global rate of change (GROC). Independent t-tests were used to assess change from baseline and differences between treatment groups. ClinicalTrials.gov: NCT02135094.

Results

There was a 100% completion rate for participants enrolled in the study and no significant differences between the groups regarding demographic variables or baseline outcome measures. Participants treated with active therapy observed a significant mean pain reduction from baseline of 2.61 points for active (p<0.001), compared to 1.58 points decrease from baseline for placebo (p=0.087), resulting in a 1.03 points significant decrease in the active group over placebo (p=0.003). The total GROC was significantly higher in the active group at 2.84 points compared to the placebo group at 0.46 points (p<0.001).

Conclusion

Low-intensity continuous ultrasound treatment significantly reduced pain in patients with upper trapezius myofascial pain of the neck and shoulder. LICUS treatment showed a clinically meaningful improvement in the GROC scores for patients. The results from this clinical trial indicate that the LICUS treatment of 18,720 Joules can effectively be used to treat clinical pain related to upper trapezius myofascial pain. Further research could investigate varying dosimetry to improve efficacy and/or reduce the dose.

What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta-regression of observational studies

Guidelines now discourage opioid analgesics for chronic noncancer pain because the benefits frequently do not outweigh the harms. We aimed to determine the proportion of patients with chronic noncancer pain who are prescribed an opioid, the types prescribed and factors associated with prescribing. Database searches were conducted from inception to 29 October 2018 without language restrictions. We included observational studies of adults with chronic noncancer pain measuring opioid prescribing. Opioids were categorized as weak (e.g. codeine) or strong (e.g. oxycodone). Study quality was assessed using a risk of bias tool designed for observational studies measuring prevalence. Individual study results were pooled using a random-effects model. Meta-regression investigated study-level factors associated with prescribing (e.g. sampling year, geographic region as per World Health Organization). The overall evidence quality was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria. Of the 42 studies (5,059,098 participants) identified, the majority (n = 28) were from the United States of America. Eleven studies were at low risk of bias. The pooled estimate of the proportion of patients with chronic noncancer pain prescribed opioids was 30.7% (95% CI 28.7% to 32.7%, n = 42 studies, moderate-quality evidence). Strong opioids were more frequently prescribed than weak (18.4% (95% CI 16.0-21.0%, n = 15 studies, low-quality evidence), versus 8.5% (95% CI 7.2-9.9%, n = 15 studies, low-quality evidence)). Meta-regression determined that opioid prescribing was associated with year of sampling (more prescribing in recent years) (P = 0.014) and not geographic region (P = 0.056). Opioid prescribing for patients with chronic noncancer pain is common and has increased over time.

How does reduction in pain lead to reduction in disability in patients with musculoskeletal pain?

Purpose

Reduction in pain following multidisciplinary treatment is most often associated with a reduction in disability. To further elaborate the relationship between pain intensity and disability, the present study investigated three main questions: first, whether multidisciplinary treatment leads to a significant improvement in pain, disability and psychological variables (depression, pain acceptance and catastrophizing). Second, it was examined whether pain reduction may account for significant changes in the psychological variables (pre- to follow-up change scores). Finally, it was analyzed whether the psychological changes mediate the association between reduction in pain and in disability after controlling for age, sex and pain history.

Patients and methods

Patients suffering from chronic musculoskeletal pain (n=279) attended a German inpatient multidisciplinary program lasting 15 consecutive days on average, with self-report data collected at pretreatment, posttreatment and three-month follow-up.

Results

Repeated measures ANOVAs showed a significant improvement in pain intensity, disability, pain acceptance, catastrophizing and depression at posttreatment and follow-up. Univariate regression analyses revealed that changes in pain intensity accounted for significant changes in depression, pain catastrophizing and pain acceptance (pre- to follow-up change scores). The results of Multiple Mediation Procedure showed that pain reduction did affect reduction in disability through improvement of depression, catastrophizing and acceptance.

Conclusion

Our findings support a cognitive-behavioral model of pain that posits an important role for pain-related cognitive and emotional processes in long-term outcomes following multidisciplinary pain treatment, in particular for the modulation of disability due to pain. The results add evidence to the notion that pain-related cognitions are dynamic features varying over time dependent on the internal situation.

Perspective

The current findings are relevant to the management of patients with musculoskeletal pain. The results support the notion that, in contrast with the view of enduring personality traits, pain-related cognitions and emotions reflect a situational response that varies over time.

Whole Body Vibration Exercise for Chronic Musculoskeletal Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This study systematically reviews previous work on the effects of whole body vibration exercise (WBVE) on pain associated with chronic musculoskeletal disorders.

DATA SOURCES

Seven electronic databases (PubMed, Embase, CINAHL, Web of Science, Cochrane, Physiotherapy Evidence Database [PEDro], and the China National Knowledge Infrastructure) were searched for articles published between January 1980 and September 2018.

STUDY SELECTION

Randomized controlled trials involving adults with chronic low back pain (CLBP), osteoarthritis (OA), or fibromyalgia were included. Participants in the WBVE intervention group were compared with those in the nontreatment and non-WBVE control groups.

DATA EXTRACTION

Data were independently extracted using a standardized form. Methodological quality was assessed using PEDro.

DATA SYNTHESIS

Suitable data from 16 studies were pooled for meta-analysis. A random effects model was used to calculate between-groups mean differences at 95% confidence interval (CI). The data were analyzed depending on the duration of the follow-up, common disorders, and different control interventions.

RESULTS

Alleviation of pain was observed at medium term (standardized mean difference [SMD], -0.67; 95% CI, -1.14 to -0.21; I², 80%) and long term (SMD, -0.31; 95% CI, -0.59 to -0.02; I², 0%). Pain was alleviated in osteoarthritis (OA) (SMD, -0.37; 95% CI, -0.64 to -0.10; P<.05; I², 22%) and CLBP (SMD, -0.44; 95% CI, -0.75 to -0.13; P<.05; I², 12%). Long-term WBVE could relieve chronic musculoskeletal pain conditions of OA (SMD, -0.46; 95% CI, -0.80 to -0.13; P<.05; I², 0%). WBVE improved chronic musculoskeletal pain compared with the treatment "X" control (SMD, -0.37; 95% CI, -0.61 to -0.12; P<.05; I², 26%), traditional treatment control (SMD, -1.02; 95% CI, -2.44 to 0.4; P>.05; I², 94%) and no treatment control (SMD, -1; 95% CI, -1.76 to -0.24; P<.05; I², 75%).

CONCLUSIONS

Evidence suggests positive effects of WBVE on chronic musculoskeletal pain, and long durations of WBVE could be especially beneficial. However, WBVE does not significantly relieve chronic musculoskeletal pain compared with the traditional treatment. Further work is required to identify which parameters of WBVE are ideal for patients with chronic musculoskeletal pain.

BEEP-Bodily and Emotional Perception of Pain. A Questionnaire to Measure Reaction to Pain in Chronic Pain Disorders

Background: The assessment of pain and its impact on quality of life is central to the evaluation of chronic pain syndromes. However, most available tools focus on the nociceptive experience of pain, and at best only consider the occurrence of anxious, depressive, or cognitive problems. Here is a new questionnaire aimed at measuring the multifaceted impact of pain in chronic pain syndromes, the Bodily and Emotional pErception of Pain (BEEP).

Methods: All consecutive patients who accessed a center for the treatment of pain were invited to take part in the study. The sample included 222 participants (51 with fibromyalgia, 84 with low back pain; 87 with other chronic pain syndromes). Women were 77% of the sample, the mean age was 61 ± 15. Participants completed the BEEP, the Patient Health Questionnaire-9 (PHQ-9), and the Mood Disorder Questionnaire (MDQ).

Results: Reliability was good for all questionnaires. The expected three dimensions of the BEEP were confirmed by confirmatory factor analysis, and a bifactor model with three orthogonal factors showed a good fit as well. Participants diagnosed with fibromyalgia showed higher scores on the BEEP than the participants who had been diagnosed with low back pain or other chronic pain syndromes. The prevalence of probable cases of major depression and bipolar disorder in the sample was higher than expected for non-clinical samples. Levels of depression, as measured by the PHQ-9, were associated with the three dimensions of the BEEP and with the intensity of pain.

Conclusions: The BEEP is a promising measure of the impact of pain in daily life and differentiates fibromyalgia from other chronic pain syndromes. The BEEP may be helpful to evaluate the patient's response to the treatment over time and may favor the identification of unmet needs in patients' personal, social, and daily functioning.

Analgesic Effect and Potential Cumulative Benefit from Caudal Epidural D5W in Consecutive Participants with Chronic Low-Back and Buttock/Leg Pain

Objectives: Chronic low-back pain (CLBP) participants in a prior controlled study reported short-term pain relief after caudal epidural injection of 5% dextrose (D5W). This study assessed whether repeated caudal epidural injections of D5W results in serial short-term diminution of CLBP and progressive long-term decrease in pain and disability.

Design: Prospective uncontrolled study.

Settings/Location: Outpatient pain clinic.

Subjects: Adults with CLBP with radiation to gluteal or leg areas.

Interventions: Caudal epidural injection of 10 mL of D5W (without anesthetic) every 2 weeks for four treatments and then as needed for 1 year.

Outcome measures: Numerical Rating Scale (NRS, pain, 0–10 points), Oswestry Disability Index (ODI, disability, %), and fraction of participants with ≥50% reduction in NRS score. Analysis by intention to treat.

Results: Participants (n = 32, 55 ± 9.8 years old, nine female) had moderate-to-severe CLBP (6.5 ± 1.2 NRS points) for 11.1 ± 10.8 years. They received 5.5 ± 2.9 caudal D5W injections through 12 months of follow-up. The data capture rate for analysis was 94% at 12 months for NRS and ODI outcome measures, with 6% carried forward by intention to treat. A consistent pattern of analgesia was demonstrated after D5W injection. Compared with baseline status, NRS and ODI scores improved by 3.4 ± 2.3 (52%) and 18.2 ± 16.4% (42%) points, respectively. The fraction of participants with 50% reduction in NRS-based pain was 21/32 (66%).

Conclusion: Epidural D5W injection, in the absence of anesthetic, resulted in consistent postinjection analgesia and clinically significant improvement in pain and disability through 12 months for most participants. The consistent pattern postinjection analgesia suggests a potential sensorineural effect of dextrose on neurogenic pain.

"It's Better in a Group Anyway": Patient Experiences of Group and Individual Acupuncture

OBJECTIVES

Chronic pain is prevalent, burdensome, and costly, and there are ethnic and racial disparities in treatment. Acupuncture is effective and safe, but access is limited. Group acupuncture can decrease cost and increase capacity by decreasing clinic space needs and increasing patient volume per acupuncturist; however, the effectiveness and patient acceptability of group and individual session acupuncture have never been directly compared.

DESIGN

The Acupuncture Approaches to Decrease Disparities in Pain Treatment (AADDOPT-2) study is a randomized comparative effectiveness trial of acupuncture for chronic pain. Semistructured in-depth interviews were conducted with a subset of patients enrolled in the trial.

SETTINGS/LOCATION

Outpatient clinics in an urban, low income area serving a primarily black and Hispanic population.

SUBJECTS

Qualitative interviews were conducted with 46 patients; 23 in each arm of the AADDOPT-2 study.

INTERVENTIONS

Patients were randomized to receive either individual acupuncture or acupuncture delivered in a small group.

OUTCOME MEASURES

Transcripts of the interviews were analyzed using an inductive thematic framework to explore and compare the patient experience in group and individual settings.

RESULTS

Patients in both study arms valued the pain relief, improved quality of life, and relaxation experienced during acupuncture. Privacy and mixed-sex groups were cited as a concern by a minority of patients; however, most of those randomized to the group setting noted that these concerns abated after initiating treatment. Differences between arms included the depth of the relationship with the acupuncturist and misgivings related to the treatment space. Group dynamics varied; some groups fostered a supportive, therapeutic interaction, while others were more reserved.

CONCLUSIONS

Patients in both arms valued their acupuncture experience. Participants described both positive and negative aspects of the group setting.

Challenges in the Analysis of Outcomes for Surgical Compared to Radiotherapy Treatment of Prostate Cancer

BACKGROUND/AIM

Prostate cancer can be treated with radical prostatectomy (RP), external-beam radiotherapy (EBRT), or brachytherapy (BT). These modalities have similar cancer-related outcomes. We used an innovative method to analyze the cost of such treatment.

MATERIALS AND METHODS

We queried our Institution's Insurance Division [University of Pittsburgh Medical Center (UPMC) Health Plan] beneficiaries from 2003-2008, who were diagnosed with prostate cancer and also queried the UPMC tumor registry for all patients with prostate cancer treated at our Institution. In a de-identified manner, data from the Health Plan and Tumor Registry were merged.

RESULTS

A total of 354 patients with non-metastatic disease with treatment initiated within 9 months of diagnosis were included (RP=236, EBRT=55, and BT=63). Radiotherapy-treated patients tended to be older, higher-risk, and have more comorbidities. Unadjusted median total health care expenditures during the first year after diagnosis were: RP: $16,743, EBRT: $47,256, and BT: $23,237 (p<0.0005). A propensity score-matched model comparing RP and EBRT demonstrated median total health care expenditures during year one: RP: $8,189, EBRT: $10,081; p=0.48. In a propensity-matched model comparing RP and BT, the median total health care expenditures during year one were: RP: $18,143, BT: $26,531; p=0.015 and per year during years 2 through 5 from diagnosis were: RP: $5,913, BT: $6,110; p=0.68.

CONCLUSION

This pilot study demonstrates the feasibility of combining healthcare costs from the payer's perspective with clinical data from a Tumor Registry within an IDFS and represents a novel approach to investigating the economic impact of cancer treatment.

Pharmacoeconomics of genotyping-based treatment decisions in patients with chronic pain

INTRODUCTION

Genotyping-based treatment decisions may optimize treatment response and minimize adverse drug events (ADEs) in patients with chronic pain.

OBJECTIVES

To estimate the financial impact of genotyping-based treatment decisions in patients with moderate to severe chronic pain in a managed care setting.

METHODS

A budget impact model was built with a 1-year time horizon to estimate costs of genotyping-based treatment decisions in a 1000-patient cohort. The model includes drug costs, type and cost of ADEs, distribution of treatments used, and genotyping costs. Event rates and health care costs were derived from primary literature. Three patient cohorts were assessed with and without genotyping-based treatment decisions: no genetic testing; 50% genetic testing; and 100% genetic testing. Sensitivity analysis was performed varying costs, adherence, and the percentage of patients treated according to genotyping results.

RESULTS

Medical and ADE costs varied by patient severity and genotyping rates. Without genotyping, drug and ADE costs ranged from $1,544,377 to $24,313,844. With genotyping-based treatment, total costs ranged from $1,780,922 to $18,868,032. Sensitivity analysis, varying costs, adherence, and genotyping rates suggested genotyping improves outcomes and is cost saving in patients with chronic pain.

CONCLUSION

Genotyping-based treatment costs are offset by reduced medication utilization and adverse event costs. Genotyping should be considered for patients with chronic pain in clinical practice and within clinical trials.