1
|
You DS, Chong JL, Mackey SC, Poupore-King H. Utilizing a learning health system to capture real-world patient data: Application of the reliable change index to evaluate and improve the outcome of a pain rehabilitation program. Pain Pract 2024. [PMID: 38465804 DOI: 10.1111/papr.13364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
BACKGROUND AND OBJECTIVES The learning healthcare system (LHS) has been developed to integrate patients' clinical data into clinical decisions and improve treatment outcomes. Having little guidance on this integration process, we aim to explain (a) an applicable analytic tool for clinicians to evaluate the clinical outcomes at a group and an individual level and (b) our quality improvement (QI) project, analyzing the outcomes of a new outpatient pain rehabilitation program ("Back-in-Action": BIA) and applying the analysis results to modify our clinical practice. METHODS Through our LHS (CHOIR; https://choir.stanford.edu), we administered the Pain Catastrophizing Scale (PCS), Chronic Pain Acceptance Questionnaire (CPAQ), and Patient-Reported Outcomes Measures (PROMIS)® before and after BIA. After searching for appropriate analytic tools, we decided to use the Reliable Change Index (RCI) to determine if an observed change in the direction of better (improvement) or worse (deterioration) would be beyond or within the measurement error (no change). RESULTS Our RCI calculations revealed that at least a 9-point decrease in the PCS scores and 10-point increase in the CPAQ scores would indicate reliable improvement. RCIs for the PROMIS measures ranged from 5 to 8 T-score points (i.e., 0.5-0.8 SD). When evaluating change scores of the PCS, CPAQ, and PROMIS measures, we found that 94% of patients showed improvement in at least one domain after BIA and 6% showed no reliable improvement. CONCLUSIONS Our QI project revealed RCI as a useful tool to evaluate treatment outcomes at a group and an individual level, and RCI could be incorporated into the LHS to generate a progress report automatically for clinicians. We further explained how clinicians could use RCI results to modify a clinical practice, to improve the outcomes of a pain program, and to develop individualized care plans. Lastly, we suggested future research areas to improve the LHS application in pain practice.
Collapse
Affiliation(s)
- Dokyoung S You
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jeanette L Chong
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Heather Poupore-King
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| |
Collapse
|
2
|
Banerjee A, Mackey SC, Vest N, Darnall BD. Pain in US corrections settings: the promise of digital solutions for better data and treatment access. Pain Med 2024; 25:165-168. [PMID: 37950495 PMCID: PMC10906706 DOI: 10.1093/pm/pnad150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/19/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Aditya Banerjee
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, United States
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, United States
| | - Noel Vest
- Department of Community Health Science, Boston University School of Public Health, Boston, MA 02118, United States
| | - Beth D Darnall
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, United States
| |
Collapse
|
3
|
Edwards KA, Lii T, Schouten TD, Kearney KM, Ziadni MS, Darnall BD, Mackey SC, Gilam G. Is There an Association Between Lateralization of Chronic Pain in the Body and Depression? J Pain 2024:S1526-5900(24)00371-7. [PMID: 38341013 DOI: 10.1016/j.jpain.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/20/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
Depression commonly co-occurs with chronic pain and can worsen pain outcomes. Recent theoretical work has hypothesized that pain localized to the left hemibody is a risk factor for worse depression due to overlap in underlying neural substrates. This hypothesis has not been tested a priori. Using a large sample of treatment-seeking adults with mixed-etiology chronic pain (N = 1,185), our cross-sectional study tested whether patients with left-sided pain endorse worse depressive symptoms. We also examined differences in other pain-related functioning measures. We tested 4 comparisons based on painful body areas using the CHOIR body map: 1) only left-sided (OL) versus any right-sided pain; 2) only right-sided (OR) versus any left-sided pain; 3) OL versus OR versus bilateral pain; and 4) more left-sided versus more right-sided versus equal-sided pain. Analysis of variance models showed OL pain was not associated with worse depression (F = 5.50, P = .019). Any left-sided pain was associated with worse depression, though the effect was small (F = 8.58, P = .003, Cohens d = .29). Bilateral pain was associated with worse depression (F = 8.05, P < .001, Cohens d = .24-.33). Regardless of pain location, more body areas endorsed was associated with greater depression. Although a more rigorous assessment of pain laterality is needed, our findings do not support the hypothesis that left-lateralized pain is associated with worse depression. PERSPECTIVE: Pain lateralized to the left side of the body has been hypothesized as a risk factor for worse depression in chronic pain, despite never being tested in a large, real-world sample of patients with chronic pain. Findings showed that more widespread pain, not pain laterality, was associated with worse depression.
Collapse
Affiliation(s)
- Karlyn A Edwards
- Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Theresa Lii
- Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Troy D Schouten
- Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Katherine M Kearney
- Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Maisa S Ziadni
- Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Beth D Darnall
- Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Gadi Gilam
- Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, California; Institute of Biomedical and Oral Research, Faculty of Dental Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
4
|
Darnall BD, Burns JW, Hong J, Roy A, Slater K, Poupore-King H, Ziadni MS, You DS, Jung C, Cook KF, Lorig K, Tian L, Mackey SC. Empowered Relief, cognitive behavioral therapy, and health education for people with chronic pain: a comparison of outcomes at 6-month Follow-up for a randomized controlled trial. Pain Rep 2024; 9:e1116. [PMID: 38288134 PMCID: PMC10824382 DOI: 10.1097/pr9.0000000000001116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/14/2023] [Accepted: 10/09/2023] [Indexed: 01/31/2024] Open
Abstract
Introduction We previously conducted a 3-arm randomized trial (263 adults with chronic low back pain) which compared group-based (1) single-session pain relief skills intervention (Empowered Relief; ER); (2) 8-session cognitive behavioral therapy (CBT) for chronic back pain; and (3) single-session health and back pain education class (HE). Results suggested non-inferiority of ER vs. CBT at 3 months post-treatment on an array of outcomes. Methods Here, we tested the durability of treatment effects at 6 months post-treatment. We examined group differences in primary and secondary outcomes at 6 months and the degree to which outcomes eroded or improved from 3-month to 6-month within each treatment group. Results Empowered Relief remained non-inferior to CBT on most outcomes, whereas both ER and CBT remained superior to HE on most outcomes. Outcome improvements within ER did not decrease significantly from 3-month to 6-month, and indeed ER showed additional 3- to 6-month improvements on pain catastrophizing, pain bothersomeness, and anxiety. Effects of ER at 6 months post-treatment (moderate term outcomes) kept pace with effects reported by participants who underwent 8-session CBT. Conclusions The maintenance of these absolute levels implies strong stability of ER effects. Results extend to 6 months post-treatment previous findings documenting that ER and CBT exhibit similarly potent effects on outcomes.
Collapse
Affiliation(s)
- Beth D. Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - John W. Burns
- Department of Psychiatry and Behavioral Science, Rush University Medical Center, Chicago, IL, USA
| | - Juliette Hong
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Anuradha Roy
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kristin Slater
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Heather Poupore-King
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Maisa S. Ziadni
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Dokyoung S. You
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Corinne Jung
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Kate Lorig
- Department of Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lu Tian
- Department of Biomedical Data Science and (by courtesy) Statistics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sean C. Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| |
Collapse
|
5
|
You DS, Cook KF, Lannon EW, Ziadni MS, Darnall BD, Mackey SC. Establishing the interpretability and utility of the 4-item BriefPCS. Sci Rep 2023; 13:21272. [PMID: 38042937 PMCID: PMC10693612 DOI: 10.1038/s41598-023-48433-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/27/2023] [Indexed: 12/04/2023] Open
Abstract
To reduce the patient burden associated with completing the 13-item Pain Catastrophizing Scale (PCS), the 4-item "BriefPCS" was developed. To date, no crosswalk has been developed that associates scores on the BriefPCS with PCS scores. Further, no study has compared the use of BriefPCS and PCS scores in a randomized clinical trial (RCT). We aimed to: (1) establish the interpretability of BriefPCS scores in reference to PCS scores, (2) compare the concurrent validity between the BriefPCS and PCS, and (3) asssess the use of BriefPCS in an RCT. First, we conducted equipercentile linking, created a crosswalk that associated scores of BriefPCS with PCS, and calculated differences between PCS and crosswalked PCS scores. Secondly, we compared Bootstrap correlation coefficients between PCS and self-reported measures of other domains. Lastly, we compared results from an RCT using BriefPCS scores versus PCS scores. Findings indicated that the correlation coefficient estimates with the BriefPCS and PCS scores were not significantly different. BriefPCS and PCS scores had similar ability to detect treatment-related changes. The BriefPCS scores validly, reliably, and accurately distinguish levels of pain catastrophizing. Additionally, the BriefPCS scores are sensitive to changes after behavioral interventions, with less respondent burden compared to the PCS scores.
Collapse
Affiliation(s)
- Dokyoung S You
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, MC 5596, Palo Alto, CA, 94304, USA.
| | - Karon F Cook
- Feral Scholars, 257 County Road 4754, Broaddus, TX, 75929, USA
| | - Edward W Lannon
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, MC 5596, Palo Alto, CA, 94304, USA
| | - Maisa S Ziadni
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, MC 5596, Palo Alto, CA, 94304, USA
| | - Beth D Darnall
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, MC 5596, Palo Alto, CA, 94304, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, MC 5596, Palo Alto, CA, 94304, USA
| |
Collapse
|
6
|
Martucci KT, Karshikoff B, Mackey SC. Links between brain neuroimaging and blood inflammatory markers in urological chronic pelvic pain syndrome. Physiol Behav 2023; 271:114358. [PMID: 37769862 PMCID: PMC10599305 DOI: 10.1016/j.physbeh.2023.114358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/12/2023] [Accepted: 09/25/2023] [Indexed: 10/02/2023]
Abstract
Urological chronic pelvic pain syndrome (UCPPS) is a debilitating painful condition with unclear etiology. Prior researchers have indicated that compared to healthy controls, patients with UCPPS demonstrated altered brain activity. Researchers have also shown that in UCPPS, several blood inflammatory markers relate to clinical variables of pain, fatigue, and pain widespreadness. However, how altered brain function in patients with UCPPS relates to blood inflammation remains unknown. To extend and connect prior findings of altered brain function and inflammatory factors in UCPPS, we conducted a secondary analysis of data from a cohort of UCPPS patients (N = 29) and healthy controls (N = 31) who provided both neuroimaging and blood data (National Institute of Health MAPP Research Network publicly available dataset). In our present study, we aimed to evaluate relationships between a priori-defined brain neuroimaging markers and inflammatory factors of interest and their relationships to pain-psychological variables. We hypothesized that two brain alterations of interest (i.e., PCC - left hippocampus functional connectivity and PCC - bilateral amygdala functional connectivity) would be correlated with four cytokine markers of interest: interleukin (IL) - 6, tumor necrosis factor-alpha (TNF-a), IL-8, and granulocyte-macrophage colony-stimulating factor (GM-CSF). In the UCPPS cohort, we identified a significant PCC - left hippocampus functional connectivity relationship with IL-6 (p = 0.0044). Additionally, in the UCPPS cohort, we identified a PCC - amygdala functional connectivity relationship with GM-CSF which did not meet our model's threshold for statistical significance (p = 0.0665). While these data are preliminary and cross-sectional, our findings suggest connections between brain function and levels of low-grade systemic inflammation in UCPPS. Thus, while further study is needed, our data indicate the potential for advancing the understanding of how brain functional circuits may relate to clinical symptoms and systemic inflammation.
Collapse
Affiliation(s)
- Katherine T Martucci
- Human Affect and Pain Neuroscience Laboratory, Center for Translational Pain Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Bianka Karshikoff
- UiS Biopsychology Research Group, Department of Social Studies, Stavanger University, Stavanger, Norway; Department of Clinical Neuroscience, Karolinska Institute, Solna, Sweden
| | - Sean C Mackey
- Stanford Neuroscience and Pain Laboratory, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA, USA
| |
Collapse
|
7
|
Hah JM, Vialard JDV, Efron B, Mackey SC, Carroll IR, Amanatullah DF, Narasimhan B, Hernandez-Boussard T. Preoperative Versus Perioperative Risk Factors for Delayed Pain and Opioid Cessation After Total Joint Arthroplasty: A Prospective Cohort Study. Pain Ther 2023; 12:1253-1269. [PMID: 37556071 PMCID: PMC10444739 DOI: 10.1007/s40122-023-00543-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/13/2023] [Indexed: 08/10/2023] Open
Abstract
INTRODUCTION The evolution of pre- versus postoperative risk factors remains unknown in the development of persistent postoperative pain and opioid use. We identified preoperative versus comprehensive perioperative models of delayed pain and opioid cessation after total joint arthroplasty including time-varying postoperative changes in emotional distress. We hypothesized that time-varying longitudinal measures of postoperative psychological distress, as well as pre- and postoperative use of opioids would be the most significant risk factors for both outcomes. METHODS A prospective cohort of 188 patients undergoing total hip or knee arthroplasty at Stanford Hospital completed baseline pain, opioid use, and emotional distress assessments. After surgery, a modified Brief Pain Inventory was assessed daily for 3 months, weekly thereafter up to 6 months, and monthly thereafter up to 1 year. Emotional distress and pain catastrophizing were assessed weekly to 6 months, then monthly thereafter. Stepwise multivariate time-varying Cox regression modeled preoperative variables alone, followed by all perioperative variables (before and after surgery) with time to postoperative opioid and pain cessation. RESULTS The median time to opioid and pain cessation was 54 and 152 days, respectively. Preoperative total daily oral morphine equivalent use (hazard ratio-HR 0.97; 95% confidence interval-CI 0.96-0.98) was significantly associated with delayed postoperative opioid cessation in the perioperative model. In contrast, time-varying postoperative factors: elevated PROMIS (Patient-Reported Outcomes Measurement Information System) depression scores (HR 0.92; 95% CI 0.87-0.98), and higher Pain Catastrophizing Scale scores (HR 0.85; 95% CI 0.75-0.97) were independently associated with delayed postoperative pain resolution in the perioperative model. CONCLUSIONS These findings highlight preoperative opioid use as a key determinant of delayed postoperative opioid cessation, while postoperative elevations in depressive symptoms and pain catastrophizing are associated with persistent pain after total joint arthroplasty providing the rationale for continued risk stratification before and after surgery to identify patients at highest risk for these distinct outcomes. Interventions targeting these perioperative risk factors may prevent prolonged postoperative pain and opioid use.
Collapse
Affiliation(s)
- Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA.
- , 1070 Arastradero Rd., Suite 200, Palo Alto, CA, 94304, USA.
| | - Julien D Veron Vialard
- Institute for Computational and Mathematical Engineering, Stanford University, Stanford, CA, USA
| | - Bradley Efron
- Departments of Statistics, Stanford University, Stanford, CA, USA
- Departments of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Ian R Carroll
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | | | - Balasubramanian Narasimhan
- Departments of Statistics, Stanford University, Stanford, CA, USA
- Departments of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Tina Hernandez-Boussard
- Departments of Biomedical Data Science, Stanford University, Stanford, CA, USA
- Department of Medicine, Stanford University, Stanford, CA, USA
- Department of Surgery, Stanford University, Stanford, CA, USA
| |
Collapse
|
8
|
Ziadni MS, Jaros S, Anderson SR, You DS, Darnall BD, Mackey SC. A Longitudinal Investigation of the Impact of COVID-19 on Patients With Chronic Pain. J Pain 2023; 24:1830-1842. [PMID: 37225065 PMCID: PMC10201913 DOI: 10.1016/j.jpain.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 05/26/2023]
Abstract
The COVID-19 pandemic prompted unexpected changes in the healthcare system. This current longitudinal study had 2 aims: 1) describe the trajectory of pandemic-associated stressors and patient-reported health outcomes among patients receiving treatment at a tertiary pain clinic over 2 years (May 2020 to June 2022); and 2) identify vulnerable subgroups. We assessed changes in pandemic-associated stressors and patient-reported health outcome measures. The study sample included 1270 adult patients who were predominantly female (74.6%), White (66.2%), non-Hispanic (80.6%), married (66.1%), not on disability (71.2%), college-educated (59.45%), and not currently working (57.9%). We conducted linear mixed effect modeling to examine the main effect of time with controlling for a random intercept. Findings revealed a significant main effect of time for all pandemic-associated stressors except financial impact. Over time, patients reported increased proximity to COVID-19, but decreased pandemic-associated stressors. A significant improvement was also observed in pain intensity, pain catastrophizing, and PROMIS-pain interference, sleep, anxiety, anger, and depression scores. Demographic-based subgroup analyses for pandemic-associated stressors revealed that younger adults, Hispanics, Asians, and patients receiving disability compensation were vulnerable groups either during the initial visit or follow-up visits. We observed additional differential pandemic effects between groups based on participant sex, education level, and working status. In conclusion, despite unanticipated changes in pain care services during the pandemic, patients receiving pain treatments adjusted to pandemic-related stressors and improved their health status over time. As the current study observed differential pandemic impacts on patient subgroups, future studies should investigate and address the unmet needs of vulnerable subgroups. PERSPECTIVE: Over a 2-year timeframe, the pandemic did not adversely influence physical and mental health among treatment-seeking patients with chronic pain. Patients reported small but significant improvements across indices of physical and psychosocial health. Differential impacts emerged among groups based on ethnicity, age, disability status, gender, education level, and working status.
Collapse
Affiliation(s)
- Maisa S Ziadni
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, California
| | - Sam Jaros
- Department of Epidemiology, Stanford University School of Medicine, Palo Alto, California
| | - Steven R Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, California
| | - Dokyoung S You
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, California
| | - Beth D Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, California
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, California
| |
Collapse
|
9
|
Karayannis NV, Sturgeon JA, Kemani MK, Mackey SC, Greco CM, Wicksell RK, McCracken LM. Pain acceptance and psychological inflexibility predict pain interference outcomes for persons with chronic pain receiving pain psychology. Scand J Pain 2023; 23:464-475. [PMID: 36745187 PMCID: PMC10522049 DOI: 10.1515/sjpain-2022-0107] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 01/14/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Awareness (being present), acceptance, and engagement (committed action) are three dimensions of psychological flexibility. Understanding these in the context of chronic pain may identify treatment targets to help refine individual treatment. Our objective was to test the predictive capacity of three dimensions within the psychological flexibility model on the longitudinal trajectory of pain interference. METHODS Patients receiving pain psychology treatment at a pain management center participated in this pragmatic clinical longitudinal study (n=86 with at least three assessments; Mean age=51 years; Gender=60 females, 26 males). Measures included the Five Facet Mindfulness Questionnaire (FFMQ-SF); Chronic Pain Acceptance Questionnaire (CPAQ-8); Psychological Inflexibility in Pain Scale (PIPS-12); and Committed Action Questionnaire (CAQ-8). The dependent variable was the Patient Reported Outcomes Information System (PROMIS) Pain Interference (PI). We used latent growth modelling to analyze scores assessed within 180 days of patient care. RESULTS Psychological inflexibility (PIPS-12) and pain acceptance (CPAQ-8) measured at baseline predicted PI outcomes (n=86). PIPS-12 showed a direct relationship with pain interference (PI), where higher PIPS-12 scores predicted significantly higher PI mean scores on average across the study period (ρ=0.422, r2=0.382) but also predicted significantly greater decreases in PI across time (ρ=-0.489, r2=0.123). Higher CPAQ-8 scores predicted significantly lower PI mean scores on average across the study period (ρ=-0.478, r2=0.453) but also significantly smaller decreases in PI across time (ρ=0.495, r2=0.076). Awareness (FFMQ-SF) and engagement (CAQ-8) were not predictive of PI outcomes. CONCLUSIONS Patients who entered pain psychology treatment with lower pain acceptance and higher psychological inflexibility showed the largest reductions in pain interference across time. These results contribute towards a novel prognostic understanding of the predictive roles of an enhancing dimension and limiting dimension of psychological flexibility.
Collapse
Affiliation(s)
| | - John A Sturgeon
- Department of Psychology, University of Washington, Seattle, USA
| | - Mike K Kemani
- Medical Unit Medical Psychology, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, Solna, Sweden
- Department of Psychology, Stress Research Institute, Stockholm University, Stockholm, Sweden
| | - Sean C Mackey
- Division of Pain Medicine, Stanford University, Stanford, USA
| | - Carol M Greco
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA
| | - Rikard K Wicksell
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Solna, Sweden
| | | |
Collapse
|
10
|
Mackey SC, Pearl RG. Pain Management: Optimizing Patient Care Through Comprehensive, Interdisciplinary Models and Continuous Innovations. Anesthesiol Clin 2023; 41:xv-xvii. [PMID: 37245956 DOI: 10.1016/j.anclin.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Sean C Mackey
- Division of Pain Medicine, Stanford University School of Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Neurosciences, and (by courtesy) Neurology, 1070 Arastradero Road, Suite 200, MC 5596, Palo Alto, CA 94304-1345, USA.
| | - Ronald G Pearl
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room H3589, Stanford, CA 94305-5640, USA.
| |
Collapse
|
11
|
Salmasi V, Terkawi AS, Mackey SC. Pragmatic Comparative Effectiveness Trials and Learning Health Systems in Pain Medicine: Opportunities and Challenges. Anesthesiol Clin 2023; 41:503-517. [PMID: 37245953 PMCID: PMC10926352 DOI: 10.1016/j.anclin.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Large randomized clinical trials or aggregates of clinical trials represent the highest levels of clinical evidence because they minimize different sources of confounding and bias. The current review provides an in-depth discussion of the challenges faced and methods we can use to overcome these obstacles to tailor novel designs of pragmatic effectiveness trials to pain medicine. The authors describe their experiences with an open-source learning health system to collect high-quality evidence and conduct pragmatic clinical trials within a busy academic pain center.
Collapse
Affiliation(s)
- Vafi Salmasi
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, USA.
| | - Abdullah Sulieman Terkawi
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, USA
| |
Collapse
|
12
|
Kwon AH, Colloca L, Mackey SC. Blinded Pain Cocktails: A Reliable and Safe Opioid Weaning Method. Anesthesiol Clin 2023; 41:371-381. [PMID: 37245948 DOI: 10.1016/j.anclin.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Weaning opioids in patients with noncancerous chronic pain often poses a challenge when psychosocial factors complicate the patient's chronic pain syndrome and opioid use. A blinded pain cocktail protocol used to wean opioid therapy has been described since the 1970s. At the Stanford Comprehensive Interdisciplinary Pain Program, a blinded pain cocktail remains a reliably effective medication-behavioral intervention. This review (1) outlines psychosocial factors that may complicate opioid weaning, (2) describes clinical goals and how to use blinded pain cocktails in opioid tapering, and (3) summarizes the mechanism of dose-extending placebos and ethical justification of its use in clinical practice.
Collapse
Affiliation(s)
- Albert Hyukjae Kwon
- Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, Redwood City, CA 94063, USA.
| | - Luana Colloca
- Pain and Translational Symptom Science, Placebo Beyond Opinions Center, School of Nursing, University of Maryland, Baltimore, 655 West Lombard Street, Room 729A, Baltimore, MD 21201, USA
| | - Sean C Mackey
- Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, Palo Alto, CA 94304, USA
| |
Collapse
|
13
|
Karayannis NV, Smuck M, Law C, Mackey SC, Gross JJ, Darnall BD, Hush J. Self-reported physical function is strongly related to pain behavior and pain interference and weakly related to physical capacity in people with chronic low back pain. Musculoskelet Sci Pract 2023; 63:102721. [PMID: 36759316 PMCID: PMC10566747 DOI: 10.1016/j.msksp.2023.102721] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/15/2022] [Accepted: 01/16/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Inclusion of self-reported and capacity-based measures may help to further elucidate the interactive link between how people think and move. OBJECTIVE To characterize the relationship between self-reported factors of physical function and pain with objective physical capacity measures. DESIGN Cross-sectional study of 328 adults with chronic low back pain (CLBP). METHOD Spearman correlations assessed the relationship between pairs of measures. Multiple linear regression models assessed the association between self-reported measures of physical function and the grouping of physical capacity measures. Self-reported measures included Roland Morris Disability Questionnaire (RMDQ), PROMIS Physical Function, Pain Behavior, and Pain Interference; Fear-Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS), and Chronic Pain Acceptance Questionnaire (CPAQ). Capacity measures included walking speed and endurance, lower extremity functional strength, lumbopelvic range of motion, and trunk endurance. RESULTS PROMIS Physical Function was directly and weakly correlated with walking speed (ρ = 0.26, 2-min walk) and inversely and weakly correlated with lower extremity strength (ρ = -0.29, 5x sit-to-stand). RMDQ was not correlated with any of the capacity-based measures. PROMIS Physical Function was inversely and moderately correlated with Pain Interference (ρ = -0.48) and Pain Behavior (ρ = -0.43), PCS (ρ = -0.36), and FABQ (ρ = -0.31). The RMDQ was strongly correlated with PROMIS Physical Function (ρ = -0.56), Pain Behavior (ρ = 0.51) and Pain Interference (ρ = 0.49); and moderately correlated with PCS (ρ = 0.37) and FABQ (ρ = 0.33). PROMIS Physical Function and RMDQ were not correlated with CPAQ. Lower scores on PROMIS Physical Function were weakly associated with lower measures of lower extremity strength (-0.30, 95% CI: -0.51 to -0.09, p = 0.005). Higher scores on RMDQ were also weakly associated with lower measures of lower extremity strength (0.26, 95% CI: 0.11 to 0.41, p = 0.001). CONCLUSIONS A strong association emerged between self-reported limitations in physical function, pain behavior, and pain interference. A weak association emerged between self-reported physical function and lower extremity strength.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Julia Hush
- MacQuarie University, Sydney, Australia.
| |
Collapse
|
14
|
Webster F, Connoy L, Longo R, Ahuja D, Amtmann D, Anderson A, Ashton-James CE, Boyd H, Chambers CT, Cook KF, Cowan P, Crombez G, Feinstein AB, Fuqua A, Gilam G, Jordan I, Mackey SC, Martins E, Martire LM, O'Sullivan P, Richards DP, Turner JA, Veasley C, Würtzen H, Yang SY, You DS, Ziadni M, Darnall BD. Patient Responses to the Term Pain Catastrophizing: Thematic Analysis of Cross-sectional International Data. J Pain 2023; 24:356-367. [PMID: 36241160 PMCID: PMC9898136 DOI: 10.1016/j.jpain.2022.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/03/2022] [Accepted: 10/04/2022] [Indexed: 11/12/2022]
Abstract
Pain catastrophizing is understood as a negative cognitive and emotional response to pain. Researchers, advocates and patients have reported stigmatizing effects of the term in clinical settings and the media. We conducted an international study to investigate patient perspectives on the term pain catastrophizing. Open-ended electronic patient and caregiver proxy surveys were promoted internationally by collaborator stakeholders and through social media. 3,521 surveys were received from 47 countries (77.3% from the U.S.). The sample was mainly female (82.1%), with a mean age of 41.62 (SD 12.03) years; 95% reported ongoing pain and pain duration > 10 years (68.4%). Forty-five percent (n = 1,295) had heard of the term pain catastrophizing; 12% (n = 349) reported being described as a 'pain catastrophizer' by a clinician with associated high levels of feeling blamed, judged, and dismissed. We present qualitative thematic data analytics for responses to open-ended questions, with 32% of responses highlighting the problematic nature of the term. We present the patients' perspective on the term pain catastrophizing, its material effect on clinical experiences, and associations with negative gender stereotypes. Use of patient-centered terminology may be important for favorably shaping the social context of patients' experience of pain and pain care. PERSPECTIVE: Our international patient survey found that 45% had heard of the term pain catastrophizing, about one-third spontaneously rated the term as problematic, and 12% reported the term was applied to them with most stating this was a negative experience. Clinician education on patient-centered terminology may improve care and reduce stigma.
Collapse
Affiliation(s)
- Fiona Webster
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Laura Connoy
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Riana Longo
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | | | - Dagmar Amtmann
- University of Washington (UW), Department of Rehabilitation Medicine, UW Center on Outcomes Research in Rehabilitation (UWCORR), Seattle, Washington, USA
| | | | - Claire E Ashton-James
- Sydney Medical School, Kolling Institute, The University of Sydney, St Leonards, New South Wales, Australia
| | | | - Christine T Chambers
- Departments of Psychology and Neuroscience & Pediatrics, Dalhousie University; Centre for Pediatric Pain Research, IWK Health, Halifax, Nova Scotia
| | | | - Penney Cowan
- American Chronic Pain Association, World Patients Alliance
| | - Geert Crombez
- Psychology and Educational Sciences, Department of Experimental Clinical and Health Psychology, Ghent University, Gent, Belgium
| | - Amanda B Feinstein
- Stanford University School of Medicine/Stanford Children's Health, Menlo Park, California, USA
| | - Anne Fuqua
- University of Alabama Birmingham, Albama, USA
| | - Gadi Gilam
- The Institute of Biomedical and Oral Research, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
| | - Eduarda Martins
- Centro Hospitalar Póvoa de Varzim/Vila do Conde, EPE, Portugal
| | - Lynn M Martire
- Penn State University, University Park, Pennsylvania, USA
| | - Peter O'Sullivan
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Dawn P Richards
- Five02 Labs Inc and the Canadian Arthritis Patient Alliance, Toronto, Ontario, Canada
| | - Judith A Turner
- University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - Su-Yin Yang
- Tan Tock Seng Hospital, Department of Psychology, Tan Tock Seng Hospital, Singapore
| | - Dokyoung S You
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
| | - Maisa Ziadni
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
| | - Beth D Darnall
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA.
| |
Collapse
|
15
|
Salmasi V, Nelson LM, Hong J, Mackey SC. Association of cannabis and/or opioid with quality of life and healthcare utilization in patients with chronic pain. Front Pain Res (Lausanne) 2022; 3:1015605. [PMID: 36506271 PMCID: PMC9729730 DOI: 10.3389/fpain.2022.1015605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/31/2022] [Indexed: 11/25/2022]
Abstract
Background Opioids have been commonly used to treat chronic pain, but they are associated with significant morbidity and mortality. Cannabis has been advocated as an alternative; however, a growing number of patients are now using a combination of opioid and cannabis and the impact of this combination is not well-studied. Aim We characterized use of opioid and/or cannabis in patients with chronic pain; and compared utilization of healthcare resources. Methods We conducted a cross-sectional study to determine if measures of physical, psychological and social functioning differed among patients according to whether they used opioids and/or cannabis. We used our learning healthcare system - CHOIR - to capture NIH Patient Reported Outcomes Measure Information System surveys, and legacy pain and treatment specific questions. Results Patients who report use of opioid and/or cannabis experience higher levels of physical, psychological and social distress. After adjusting for inversed weight of propensity scores, they have higher odds of visiting an emergency room, staying overnight at the hospital, and visiting a physician. Conclusion Our results show that use of opioid and/or cannabis is associated with worse baseline characteristics and outcomes. Our study however cannot determine if worse outcomes are due to the opioids and/or cannabis or simply that these patients are worse off before using opioids and/or cannabis. Thus, it is important to characterize the trajectory of these patients in a prospective longitudinal study.
Collapse
Affiliation(s)
- Vafi Salmasi
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States,Correspondence: Vafi Salmasi
| | - Lorene M. Nelson
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Juliette Hong
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Sean C. Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| |
Collapse
|
16
|
Salmasi V, Lii TR, Humphreys K, Reddy V, Mackey SC. A literature review of the impact of exclusion criteria on generalizability of clinical trial findings to patients with chronic pain. Pain Rep 2022; 7:e1050. [PMID: 36398200 PMCID: PMC9663135 DOI: 10.1097/pr9.0000000000001050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/12/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
The ability of clinical trials to inform the care of chronic pain may be limited if only an unrepresentative subset of patients are allowed to enroll. We summarize and report new insights on published studies that report on how trial exclusions affect the generalizability of their results. We conducted a PubMed search on the following terms: (("eligibility criteria" AND generalizability) OR ("exclusion criteria" AND generalizability) OR "exclusion criteria"[ti] OR "eligibility criteria"[ti]) AND pain. We only considered studies relevant if they analyzed data on (1) the prevalence and nature of exclusion criteria or (2) the impact of exclusion criteria on sample representativeness or study results. The 4 articles that were identified reported differences in patients who were included and excluded in different clinical trials: excluded patients were older, less likely to have a paid job, had more functional limitations at baseline, and used strong opioids more often. The clinical significance of these differences remains unclear. The pain medicine literature has very few published studies on the prevalence and impact of exclusion criteria, and the outcomes of excluded patients are rarely tracked. The frequent use of psychosocial exclusions is especially compromising to generalizability because chronic pain commonly co-occurs with psychiatric comorbidities. Inclusion of more representative patients in research samples can reduce recruitment barriers and broaden the generalizability of findings in patients with chronic pain. We also call for more studies that examine the use of exclusion criteria in chronic pain trials to better understand their implications.
Collapse
Affiliation(s)
- Vafi Salmasi
- Departments of Anesthesiology, Perioperative and Pain Medicine and
| | - Theresa R. Lii
- Departments of Anesthesiology, Perioperative and Pain Medicine and
| | - Keith Humphreys
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Healthcare System, Palo Alto, CA, USA
| | - Vinay Reddy
- Departments of Anesthesiology, Perioperative and Pain Medicine and
| | - Sean C. Mackey
- Departments of Anesthesiology, Perioperative and Pain Medicine and
| |
Collapse
|
17
|
Park SH, Baker AK, Krishna V, Mackey SC, Martucci KT. Altered resting-state functional connectivity within corticostriatal and subcortical-striatal circuits in chronic pain. Sci Rep 2022; 12:12683. [PMID: 35879602 PMCID: PMC9314446 DOI: 10.1038/s41598-022-16835-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 07/18/2022] [Indexed: 11/09/2022] Open
Abstract
Brain corticostriatal circuits are important for understanding chronic pain and highly relevant to motivation and cognitive processes. It has been demonstrated that in patients with chronic back pain, altered nucleus accumbens (NAcc)-medial prefrontal cortex (MPFC) circuit fMRI-based activity is predictive of patient outcome. We evaluated the NAcc-MPFC circuit in patients with another chronic pain condition, fibromyalgia, to extend these important findings. First, we compared fMRI-based NAcc-MPFC resting-state functional connectivity in patients with fibromyalgia (N = 32) vs. healthy controls (N = 37). Compared to controls, the NAcc-MPFC circuit's connectivity was significantly reduced in fibromyalgia. In addition, within the fibromyalgia group, NAcc-MPFC connectivity was significantly correlated with trait anxiety. Our expanded connectivity analysis of the NAcc to subcortical brain regions showed reduced connectivity of the right NAcc with mesolimbic circuit regions (putamen, thalamus, and ventral pallidum) in fibromyalgia. Lastly, in an exploratory analysis comparing our fibromyalgia and healthy control cohorts to a separate publicly available dataset from patients with chronic back pain, we identified reduced NAcc-MPFC connectivity across both the patient groups with unique alterations in NAcc-mesolimbic connectivity. Together, expanding upon prior observed alterations in brain corticostriatal circuits, our results provide novel evidence of altered corticostriatal and mesolimbic circuits in chronic pain.
Collapse
Affiliation(s)
- Su Hyoun Park
- Department of Anesthesiology, Duke University Medical Center, Durham, USA
- Duke Center for Translational Pain Medicine, Durham, USA
- Human Affect and Pain Neuroscience Lab, Department of Anesthesiology, Duke University Medical Center, Box DUMC 3094, Durham, NC, 27710, USA
| | - Anne K Baker
- Department of Anesthesiology, Duke University Medical Center, Durham, USA
- Duke Center for Translational Pain Medicine, Durham, USA
- Human Affect and Pain Neuroscience Lab, Department of Anesthesiology, Duke University Medical Center, Box DUMC 3094, Durham, NC, 27710, USA
| | - Vinit Krishna
- Department of Anesthesiology, Duke University Medical Center, Durham, USA
- Duke Center for Translational Pain Medicine, Durham, USA
- Human Affect and Pain Neuroscience Lab, Department of Anesthesiology, Duke University Medical Center, Box DUMC 3094, Durham, NC, 27710, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, USA
| | - Katherine T Martucci
- Department of Anesthesiology, Duke University Medical Center, Durham, USA.
- Duke Center for Translational Pain Medicine, Durham, USA.
- Human Affect and Pain Neuroscience Lab, Department of Anesthesiology, Duke University Medical Center, Box DUMC 3094, Durham, NC, 27710, USA.
| |
Collapse
|
18
|
Mackey SC. Clarification of Conflict of Interest Disclosure. JAMA Intern Med 2022; 182:783. [PMID: 35575774 DOI: 10.1001/jamainternmed.2022.1399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sean C Mackey
- Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University, Palo Alto, California
| |
Collapse
|
19
|
Affiliation(s)
- Sean C Mackey
- Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University, Palo Alto, California
| |
Collapse
|
20
|
Hah JM, Aivaliotis VI, Hettie G, Pirrotta LX, Mackey SC, Nguyen LA. Whole Body Pain Distribution and Risk Factors for Widespread Pain Among Patients Presenting with Abdominal Pain: A Retrospective Cohort Study. Pain Ther 2022; 11:683-699. [PMID: 35467268 PMCID: PMC9098717 DOI: 10.1007/s40122-022-00382-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/25/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Abdominal pain frequently co-occurs with pain in other body sites. Chronic overlapping pain conditions (COPCs) represent a group of widespread pain diagnoses. Our study characterized how patterns of somatic pain distribution are associated with COPCs and aimed to characterize predictors of widespread pain among patients with chronic abdominal pain. Methods This retrospective cohort study included adults presenting to a tertiary pain clinic, reporting abdominal pain at their initial visit, and with a follow-up visit at 12 months. Body maps divided patients into localized, intermediate, and widespread pain distribution patterns. Diagnostic and psychosocial measures were assessed across groups at the initial and follow-up visits. We analyzed the association of baseline diagnoses and demographics and time-varying changes in psychosocial measures from initial to follow-up visit with changes in pain distribution over time with alternating logistic regression (ALR). Results Among 258 patients, most were female (91.5%) and reported widespread pain (61.5%). Those with widespread pain at baseline reported elevated anger and 60.0% of patients remained in the same pain category at follow-up. Multivariable ALR demonstrated higher pain interference (AOR 1.06, 95% CI 1.02–1.10, P = 0.002), higher anxiety (AOR 1.05, 95% CI 1.01–1.09, P = 0.01), more than one COPC at initial visit (AOR 2.85, 95% CI 1.59–5.11, P = 0.0005), and initial visit widespread pain categorization (AOR 4.18, 95% CI 2.20–8.00, P < 0.0001) were associated with an increased risk of widespread pain at the follow-up visit. Conclusion Most patients with abdominal pain report additional pain locations at multiple other body sites, and non-localized pain persists 12 months after pain treatment. Screening for widespread pain and COPC at the initial visit may identify patients at higher risk for persistent or new-onset widespread pain, and interventions to reduce pain interference and anxiety may promote reversal of widespread pain.
Collapse
Affiliation(s)
- Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Vasiliki I Aivaliotis
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Gabrielle Hettie
- Systems Neuroscience and Pain Lab, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Luke X Pirrotta
- Systems Neuroscience and Pain Lab, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Linda A Nguyen
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA
| |
Collapse
|
21
|
Affiliation(s)
- Sean C Mackey
- Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University, Palo Alto, California
| |
Collapse
|
22
|
Ziadni MS, You DS, Cramer EM, Anderson SR, Hettie G, Darnall BD, Mackey SC. The impact of COVID-19 on patients with chronic pain seeking care at a tertiary pain clinic. Sci Rep 2022; 12:6435. [PMID: 35440688 PMCID: PMC9017421 DOI: 10.1038/s41598-022-10431-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 04/06/2022] [Indexed: 02/07/2023] Open
Abstract
Empirical data on the health impacts of the COVID-19 pandemic remain scarce, especially among patients with chronic pain. We conducted a cross-sectional study matched by season to examine patient-reported health symptoms among patients with chronic pain pre- and post-COVID-19 pandemic onset. Survey responses were analyzed from 7535 patients during their initial visit at a tertiary pain clinic between April 2017-October 2020. Surveys included measures of pain and pain-related physical, emotional, and social function. The post-COVID-19 onset cohort included 1798 initial evaluations, and the control pre-COVID-19 cohort included 5737 initial evaluations. Patients were majority female, White/Caucasian, and middle-aged. The results indicated that pain ratings remained unchanged among patients after the pandemic onset. However, pain catastrophizing scores were elevated when COVID-19 cases peaked in July 2020. Pain interference, physical function, sleep impairment, and emotional support were improved in the post-COVID-19 cohort. Depression, anxiety, anger, and social isolation remained unchanged. Our findings provide evidence of encouraging resilience among patients seeking treatment for pain conditions in the face of the COVID-19 pandemic. However, our findings that pain catastrophizing increased when COVID-19 cases peaked in July 2020 suggests that future monitoring and consideration of the impacts of the pandemic on patients' pain is warranted.
Collapse
Affiliation(s)
- Maisa S Ziadni
- Systems Neuroscience and Pain Lab, Division of Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA.
| | - Dokyoung S You
- Systems Neuroscience and Pain Lab, Division of Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| | - Eric M Cramer
- Systems Neuroscience and Pain Lab, Division of Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| | - Steven R Anderson
- Systems Neuroscience and Pain Lab, Division of Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| | - Gabrielle Hettie
- Systems Neuroscience and Pain Lab, Division of Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| | - Beth D Darnall
- Systems Neuroscience and Pain Lab, Division of Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| | - Sean C Mackey
- Systems Neuroscience and Pain Lab, Division of Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| |
Collapse
|
23
|
You DS, Ziadni MS, Hettie G, Darnall BD, Cook KF, Von Korff MR, Mackey SC. Comparing Perceived Pain Impact Between Younger and Older Adults With High Impact Chronic Pain: A Cross-Sectional Qualitative and Quantitative Survey. Front Pain Res (Lausanne) 2022; 3:850713. [PMID: 35465295 PMCID: PMC9030949 DOI: 10.3389/fpain.2022.850713] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/07/2022] [Indexed: 01/19/2023]
Abstract
High impact chronic pain (HICP) is a recently proposed concept for treatment stratifying patients with chronic pain and monitoring their progress. The goal is to reduce the impact of chronic pain on the individual, their family, and society. The US National Pain Strategy defined HICP as the chronic pain associated with substantial restrictions on participation in work, social, and self-care activities for at least 6 months. To understand the meaning and characteristics of HICP from the younger (<65 years old) and older adults (≥65 years old) with chronic pain, our study examined patients' perceived pain impact between the two age groups. We also characterize the degree of pain impact, assessed with the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI), between adults and older adults with HICP. We recruited patients at a tertiary pain clinic. The survey included open-ended questions about pain impact, the Graded Chronic Pain Scale-Revised to identify patients' meeting criteria for HICP, and the Patient-Reported Outcomes Measurement Information System (PROMIS®) 8-item PI short form (v.8a). A total of 55 younger adults (65.5% women, 72.7% HICP, mean age = 55.0 with SD of 16.2) and 28 older adults (53.6% women, 64.3% HICP, mean age = 72.6 with SD of 5.4) with chronic pain participated in this study. In response to an open-ended question in which participants were asked to list out the areas of major impact pain, those with HICP in the younger group most commonly listed work, social activity, and basic physical activity (e.g., walking and standing); for those in the older group, basic physical activity, instrumental activity of daily living (e.g., housework, grocery shopping), and participating in social or fun activity for older adults with HICP were the most common. A 2 × 2 ANOVA was conducted using age (younger adults vs. older adults) and HICP classification (HICP vs. No HICP). A statistically significant difference was found in the PROMIS-PI T-scores by HICP status (HICP: M = 58.4, SD = 6.3; No HICP: M = 67.8, SD = 6.3), but not by age groups with HICP. In conclusion, perceived pain impacts were qualitatively, but not quantitatively different between younger and older adults with HICP. We discuss limitations and offer recommendations for future research.
Collapse
Affiliation(s)
- Dokyoung S. You
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Maisa S. Ziadni
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Gabrielle Hettie
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Beth D. Darnall
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | - Michael R. Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Sean C. Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States,*Correspondence: Sean C. Mackey
| |
Collapse
|
24
|
Ashton-James CE, Anderson SR, Mackey SC, Darnall BD. Beyond pain, distress, and disability: the importance of social outcomes in pain management research and practice. Pain 2022; 163:e426-e431. [PMID: 34252908 PMCID: PMC8742845 DOI: 10.1097/j.pain.0000000000002404] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 06/30/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Claire E Ashton-James
- School of Medicine, Faculty of Medicine and Health, The University of Sydney, Australia
| | - Steven R Anderson
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, United States
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, United States
| | - Beth D Darnall
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, United States
| |
Collapse
|
25
|
Humphreys K, Shover CL, Andrews CM, Bohnert ASB, Brandeau ML, Caulkins JP, Chen JH, Cuéllar MF, Hurd YL, Juurlink DN, Koh HK, Krebs EE, Lembke A, Mackey SC, Larrimore Ouellette L, Suffoletto B, Timko C. Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet Commission. Lancet 2022; 399:555-604. [PMID: 35122753 PMCID: PMC9261968 DOI: 10.1016/s0140-6736(21)02252-2] [Citation(s) in RCA: 157] [Impact Index Per Article: 78.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 08/01/2021] [Accepted: 10/06/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Keith Humphreys
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Chelsea L Shover
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Christina M Andrews
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Amy S B Bohnert
- Department of Psychiatry and Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA; Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Huang Engineering Center, Stanford University, Stanford, CA USA
| | | | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA; Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Yasmin L Hurd
- Addiction Institute, Icahn School of Medicine, New York, NY, USA
| | - David N Juurlink
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Howard K Koh
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Erin E Krebs
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Center for Care Delivery and Outcomes Research, Veterans Affairs Minneapolis Health Care System, Minneapolis, MN, USA
| | - Anna Lembke
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Brian Suffoletto
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Christine Timko
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| |
Collapse
|
26
|
You DS, Ziadni MS, Cooley CE, Talavera DC, Mackey SC, Poupore-King H. Effectiveness of a multidisciplinary rehabilitation program in real-world patients with chronic back pain: A pilot cohort data analysis. J Back Musculoskelet Rehabil 2021; 34:965-973. [PMID: 34151829 PMCID: PMC8673504 DOI: 10.3233/bmr-200305] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Randomized clinical trials (RCT) suggest a multidisciplinary approach to pain rehabilitation is superior to other active treatments in improving pain intensity, function, disability, and pain interference for patients with chronic pain, with small effect size (ds= 0.20-0.36) but its effectiveness remains unknown in real-world practice. OBJECTIVE The current study examined the effectiveness of a multidisciplinary program to a cognitive and behavioral therapy (pain-CBT) in real-world patients with chronic back pain. METHODS Twenty-eight patients (M𝑎𝑔𝑒= 57.6, 82.1% Female) completed a multidisciplinary program that included pain psychology and physical therapy. Eighteen patients (M𝑎𝑔𝑒= 58.9, 77.8% Female) completed a CBT-alone program. Using a learning healthcare system, the Pain Catastrophizing Scale, 0-10 Numerical Pain Rating Scale, and Patient-Reported Outcomes Measurement Information System® measures were administered before and after the programs. RESULTS We found significant improvement in mobility and pain behavior only after a multidisciplinary program (p's < 0.031; d= 0.69 and 0.55). We also found significant improvement in pain interference, fatigue, depression, anxiety, social role satisfaction, and pain catastrophizing after pain-CBT or multidisciplinary programs (p's < 0.037; ds = 0.29-0.73). Pain ratings were not significantly changed by either program (p's > 0.207). CONCLUSIONS The effect of a multidisciplinary rehabilitation program observed in RCT would be generalizable to real-world practice.
Collapse
Affiliation(s)
- Dokyoung S. You
- Corresponding author: Dokyoung S. You, Department Anesthesiology, Perioperative and Pain Medicine, 1070 Arastradero Road, Suite 200, MC 5596, Palo Alto, CA 94304, USA. Tel.: +1 650 724 9320; E-mail:
| | | | | | | | | | | |
Collapse
|
27
|
Gilam G, Cramer EM, Webber KA, Ziadni MS, Kao MC, Mackey SC. Classifying chronic pain using multidimensional pain-agnostic symptom assessments and clustering analysis. Sci Adv 2021; 7:eabj0320. [PMID: 34516888 PMCID: PMC8442889 DOI: 10.1126/sciadv.abj0320] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/19/2021] [Indexed: 05/26/2023]
Abstract
Chronic pain conditions present in various forms, yet all feature symptomatic impairments in physical, mental, and social domains. Rather than assessing symptoms as manifestations of illness, we used them to develop a chronic pain classification system. A cohort of real-world treatment-seeking patients completed a multidimensional patient-reported registry as part of a routine initial evaluation in a multidisciplinary academic pain clinic. We applied hierarchical clustering on a training subset of 11,448 patients using nine pain-agnostic symptoms. We then validated a three-cluster solution reflecting a graded scale of severity across all symptoms and eight independent pain-specific measures in additional subsets of 3817 and 1273 patients. Negative affect–related factors were key determinants of cluster assignment. The smallest subset included follow-up assessments that were predicted by baseline cluster assignment. Findings provide a cost-effective classification system that promises to improve clinical care and alleviate suffering by providing putative markers for personalized diagnosis and prognosis.
Collapse
Affiliation(s)
- Gadi Gilam
- Division of Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Eric M. Cramer
- Division of Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kenneth A. Webber
- Division of Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Maisa S. Ziadni
- Division of Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ming-Chih Kao
- Division of Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sean C. Mackey
- Division of Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| |
Collapse
|
28
|
Martucci KT, Weber KA, Mackey SC. Spinal Cord Resting State Activity in Individuals With Fibromyalgia Who Take Opioids. Front Neurol 2021; 12:694271. [PMID: 34421798 PMCID: PMC8371264 DOI: 10.3389/fneur.2021.694271] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/28/2021] [Indexed: 11/24/2022] Open
Abstract
Chronic pain coincides with myriad functional alterations throughout the brain and spinal cord. While spinal cord mechanisms of chronic pain have been extensively characterized in animal models and in vitro, to date, research in patients with chronic pain has focused only very minimally on the spinal cord. Previously, spinal cord functional magnetic resonance imaging (fMRI) identified regional alterations in spinal cord activity in patients (who were not taking opioids) with fibromyalgia, a chronic pain condition. Here, in patients with fibromyalgia who take opioids (N = 15), we compared spinal cord resting-state fMRI data vs. patients with fibromyalgia not taking opioids (N = 15) and healthy controls (N = 14). We hypothesized that the opioid (vs. non-opioid) patient group would show greater regional alterations in spinal cord activity (i.e., the amplitude of low frequency fluctuations or ALFF, a measure of regional spinal cord activity). However, we found that regional spinal cord activity in the opioid group was more similar to healthy controls, while regional spinal cord activity in the non-opioid group showed more pronounced differences (i.e., ventral increases and dorsal decreases in regional ALFF) vs. healthy controls. Across patient groups, self-reported fatigue correlated with regional differences in spinal cord activity. Additionally, spinal cord functional connectivity and graph metrics did not differ among groups. Our findings suggest that, contrary to our main hypothesis, patients with fibromyalgia who take opioids do not have greater alterations in regional spinal cord activity. Thus, regional spinal cord activity may be less imbalanced in patients taking opioids compared to patients not taking opioids.
Collapse
Affiliation(s)
- Katherine T Martucci
- Human Affect and Pain Neuroscience Laboratory, Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Kenneth A Weber
- Systems Neuroscience and Pain Laboratory, Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, United States
| | - Sean C Mackey
- Systems Neuroscience and Pain Laboratory, Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, United States
| |
Collapse
|
29
|
Taub CJ, Sturgeon JA, Chahal MK, Kao MC, Mackey SC, Darnall BD. Self-reported traumatic etiology of pain and psychological function in tertiary care pain clinic patients: a collaborative health outcomes information registry (CHOIR) study. Scand J Pain 2021; 20:499-509. [PMID: 32191626 DOI: 10.1515/sjpain-2019-0154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 02/13/2020] [Indexed: 11/15/2022]
Abstract
Background and aims A sizable body of research has elucidated the significant role of psychological reactions to trauma on pain coping and outcomes. In order to best inform intervention development and clinical care for patients with both trauma and pain at the tertiary care level, greater clarity is needed regarding the magnitude of these effects and the specific pathways through which they may or may not function at the time of first presentation to such a treatment setting. To achieve this, the current study examined the cross-sectional relationships between traumatic etiology of pain, psychological distress (anger, depressive symptoms, and PTSD symptoms), and pain outcomes (pain catastrophizing, physical function, disability status). Methods Using a structural path modeling approach, analyses were conducted using a large sample of individuals with chronic pain (n = 637) seeking new medical evaluation at a tertiary pain management center, using the Collaborative Health Outcomes Information Registry (CHOIR). We hypothesized that the relationships between traumatic etiology of pain and poorer pain outcomes would be mediated by higher levels of psychological distress. Results Our analyses revealed modest relationships between self-reported traumatic etiology of pain and pain catastrophizing, physical function, and disability status. In comparison, there were stronger relationships between indices of psychological distress and pain catastrophizing, but a weaker pattern of associations between psychological distress and physical function and disability measures. Conclusions To the relatively small extent that self-reported traumatic etiology of pain correlates with pain-related outcomes, these relationships appear to be due primarily to the presence of psychiatric symptoms and manifest most notably in the context of psychological responses to pain (i.e. catastrophizing about pain). Implications Findings from this study highlight the need for early intervention for patients with traumatic onset of pain and for clinicians at tertiary pain centers to include more detailed assessments of psychological distress and trauma as a component of comprehensive chronic pain treatment.
Collapse
Affiliation(s)
- Chloe J Taub
- University of Miami, Department of Psychology, Coral Gables, FL, USA
| | - John A Sturgeon
- University of Washington School of Medicine, Department of Anesthesiology and Pain Medicine, Seattle, WA, USA
| | - Mandeep K Chahal
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford Systems Neuroscience and Pain Laboratory, Stanford, CA, USA
| | - Ming-Chih Kao
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford Systems Neuroscience and Pain Laboratory, Stanford, CA, USA
| | - Sean C Mackey
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford Systems Neuroscience and Pain Laboratory, Stanford, CA, USA
| | - Beth D Darnall
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford Systems Neuroscience and Pain Laboratory, Stanford, CA, USA
| |
Collapse
|
30
|
You DS, Cook KF, Domingue BW, Ziadni MS, Hah JM, Darnall BD, Mackey SC. Customizing CAT Administration of the PROMIS Misuse of Prescription Pain Medication Item Bank for Patients with Chronic Pain. Pain Med 2021; 22:1669-1675. [PMID: 33944948 DOI: 10.1093/pm/pnab159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The 22-item PROMIS®-Rx Pain Medication Misuse item bank (Bank-22) imposes a high response burden. This study aimed to characterize the performance of the Bank-22 in a computer adaptive testing (CAT) setting based on varied stopping rules. METHODS The 22 items were administered to 288 patients. We performed a CAT simulation using default stopping rules (CATPROMIS). In 5 other simulations, a "best health" response rule was added to decrease response burden. This rule stopped CAT administration when a participant selected "never" to a specified number of initial Bank-22 items (2-6 in this study, designated CATAlt2-Alt6). The Bank-22 and 7-item short form (SF-7) scores were compared to scores based on CATPROMIS, and the 5 CAT variations. RESULTS Bank-22 scores correlated highly with the SF-7 and CATPROMIS, Alt5, Alt6 scores (r=0.87-0.95) and moderately with CATAlt2- Alt4 scores (r=0.63-0.74). In all CAT conditions, the greatest differences with Bank-22 scores were at the lower end of misuse T-scores. The smallest differences with Bank-22 and CATPROMIS scores were observed with CATAlt5 and CATAlt6. Compared to the SF-7, CATAlt5 and CATAlt6 reduced overall response burden by about 42%. Finally, the correlations between PROMIS-Rx Misuse and Anxiety T-scores remained relatively unchanged across the conditions (r=0.31-0.43, Ps < .001). CONCLUSIONS Applying a stopping rule based on number of initial "best health" responses reduced response burden for respondents with lower levels of misuse. The tradeoff was less measurement precision for those individuals, which could be an acceptable tradeoff when the chief concern is in discriminating higher levels of misuse.
Collapse
Affiliation(s)
- Dokyoung S You
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Benjamin W Domingue
- Stanford University Graduate School of Education, Palo Alto, California, USA
| | - Maisa S Ziadni
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer M Hah
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Beth D Darnall
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sean C Mackey
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| |
Collapse
|
31
|
Darnall BD, Roy A, Chen AL, Ziadni MS, Keane RT, You DS, Slater K, Poupore-King H, Mackey I, Kao MC, Cook KF, Lorig K, Zhang D, Hong J, Tian L, Mackey SC. Comparison of a Single-Session Pain Management Skills Intervention With a Single-Session Health Education Intervention and 8 Sessions of Cognitive Behavioral Therapy in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2113401. [PMID: 34398206 PMCID: PMC8369357 DOI: 10.1001/jamanetworkopen.2021.13401] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Chronic low back pain (CLBP), the most prevalent chronic pain condition, imparts substantial disability and discomfort. Cognitive behavioral therapy (CBT) reduces the effect of CLBP, but access is limited. OBJECTIVE To determine whether a single class in evidence-based pain management skills (empowered relief) is noninferior to 8-session CBT and superior to health education at 3 months after treatment for improving pain catastrophizing, pain intensity, pain interference, and other secondary outcomes. DESIGN, SETTING, AND PARTICIPANTS This 3-arm randomized clinical trial collected data from May 24, 2017, to March 3, 2020. Participants included individuals in the community with self-reported CLBP for 6 months or more and an average pain intensity of at least 4 (range, 0-10, with 10 indicating worst pain imaginable). Data were analyzed using intention-to-treat and per-protocol approaches. INTERVENTIONS Participants were randomized to (1) empowered relief, (2) health education (matched to empowered relief for duration and format), or (3) 8-session CBT. Self-reported data were collected at baseline, before treatment, and at posttreatment months 1, 2, and 3. MAIN OUTCOMES AND MEASURES Group differences in Pain Catastrophizing Scale scores and secondary outcomes at month 3 after treatment. Pain intensity and pain interference were priority secondary outcomes. RESULTS A total of 263 participants were included in the analysis (131 women [49.8%], 130 men [49.4%], and 2 other [0.8%]; mean [SD] age, 47.9 [13.8] years) and were randomized into 3 groups: empowered relief (n = 87), CBT (n = 88), and health education (n = 88). Empowered relief was noninferior to CBT for pain catastrophizing scores at 3 months (difference from CBT, 1.39 [97.5% CI, -∞ to 4.24]). Empowered relief and CBT were superior to health education for pain catastrophizing scores (empowered relief difference from health education, -5.90 [95% CI, -8.78 to -3.01; P < .001]; CBT difference from health education, -7.29 [95% CI, -10.20 to -4.38; P < .001]). Pain catastrophizing score reductions for empowered relief and CBT at 3 months after treatment were clinically meaningful (empowered relief, -9.12 [95% CI, -11.6 to -6.67; P < .001]; CBT, -10.94 [95% CI, -13.6 to -8.32; P < .001]; health education, -4.60 [95% CI, -7.18 to -2.01; P = .001]). Between-group comparisons for pain catastrophizing at months 1 to 3 were adjusted for baseline pain catastrophizing scores and used intention-to-treat analysis. Empowered relief was noninferior to CBT for pain intensity and pain interference (priority secondary outcomes), sleep disturbance, pain bothersomeness, pain behavior, depression, and anxiety. Empowered relief was inferior to CBT for physical function. CONCLUSIONS AND RELEVANCE Among adults with CLBP, a single-session pain management class resulted in clinically significant improvements in pain catastrophizing, pain intensity, pain interference, and other secondary outcomes that were noninferior to 8-session CBT at 3 months. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03167086.
Collapse
Affiliation(s)
- Beth D. Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Anuradha Roy
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Abby L. Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Maisa S. Ziadni
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Ryan T. Keane
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Dokyoung S. You
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kristen Slater
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Heather Poupore-King
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Ian Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Ming-Chih Kao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | | | - Kate Lorig
- Department of Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Dongxue Zhang
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Juliette Hong
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Lu Tian
- Department of Biomedical Data Science, Stanford University School of Medicine, Palo Alto, California
| | - Sean C. Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| |
Collapse
|
32
|
Barad MJ, Sturgeon JA, Hong J, Aggarwal AK, Mackey SC. Characterization of chronic overlapping pain conditions in patients with chronic migraine: A CHOIR study. Headache 2021; 61:872-881. [PMID: 34184263 DOI: 10.1111/head.14129] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/30/2021] [Accepted: 04/12/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Chronic overlapping pain conditions (COPCs) represent a co-aggregation of widespread pain disorders. We characterized differences in physical and psychosocial functioning in patients with chronic migraine (CM) and those with CM and COPCs. BACKGROUND Patients with CM and COPCs have been identified as a distinct subgroup of patients with CM, and these patients may be vulnerable to greater symptom severity and burden. METHODS Data were extracted from Collaborative Health Outcomes Information Registry (an open-source learning health-care system), completed at the patients' first visit at a large tertiary care pain management center and electronic medical records. In 1601 patients with CM, the number of non-cephalic areas of pain endorsed on a body map was used to examine the differences in pain, physical and psychosocial function, adverse life experience, and health-care utilization. RESULTS Patients endorsing more body map regions reported significantly worse symptoms and function across all domains. Scored on a t-score metric (mean = 50, SD = 10), endorsement of one additional body map region corresponded with a 0.69-point increase in pain interference (95% CI = 0.55, 0.82; p < 0.001; Cohen's f = 0.328), 1.15-point increase in fatigue (95% CI = 0.97, 1.32; p < 0.001; Cohen's f = 0.432), and 1.21-point decrease in physical function (95% CI = -1.39, -1.03; p < 0.001; Cohen's f = 0.560). Patients with more widespread pain reported approximately 5% more physician visits (95% CI = 0.03, 0.07; p < 0.001), and patients reporting adverse life events prior to age 17 endorsed 22% more body map regions (95% CI = 0.11, 0.32; p < 0.001). CONCLUSIONS Patients with CM and other overlapping pain conditions as noted on the body map report significantly worse pain-related physical function, psychosocial functioning, increased health-care utilization, and greater association with adverse life experiences, compared with those with localized CM. This study provides further evidence that patients with CM and co-occurring pain conditions are a distinct subgroup of CM and can be easily identified through patient-reported outcome measures.
Collapse
Affiliation(s)
- Meredith J Barad
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - John A Sturgeon
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Juliette Hong
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Anuj K Aggarwal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| |
Collapse
|
33
|
Sturgeon JA, Khan J, Hah JM, Hilmoe H, Hong J, Ware MA, Mackey SC. Clinical Profiles of Concurrent Cannabis Use in Chronic Pain: A CHOIR Study. Pain Med 2021; 21:3172-3179. [PMID: 32232476 DOI: 10.1093/pm/pnaa060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Despite evidence of the analgesic benefits of cannabis, there remains a relative scarcity of research on the short- and long-term effects of cannabis use in individuals with chronic pain. DESIGN The current study is a secondary analysis of clinical data from the Collaborative Health Outcomes Information Registry (CHOIR). SETTING Data were drawn from a cohort of patients of a multidisciplinary tertiary care pain clinic. SUBJECTS The study sample consisted of data from 7,026 new patient visits from CHOIR; of these, 1,668 patients with a follow-up time point within 180 days were included in a longitudinal analysis. METHODS Clinical data were analyzed to characterize cross-sectional differences in pain and indicators of psychological and physical function according to self-reported, concurrent cannabis use. Additionally, a propensity score-weighted longitudinal analysis was conducted, examining cannabis use as a predictor of changes in clinical variables across time. RESULTS Cross-sectional analyses suggested significantly poorer sleep and significantly higher intensities of pain, emotional distress, and physical and social dysfunction in patients reporting ongoing cannabis use; however, these differences were relatively small in magnitude. However, no differences between cannabis users and nonusers in terms of longitudinal changes in clinical variables were noted. DISCUSSION Our results are among the first to examine concurrent cannabis use as a prognostic variable regarding trajectories of pain-related variables in tertiary care. Future studies may benefit from examining the effect of cannabis initiation, concurrent medication use, and specific aspects of cannabis use (dose, duration of use, or cannabis type) on clinical outcomes.
Collapse
Affiliation(s)
- John A Sturgeon
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - James Khan
- Department of Anesthesia, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer M Hah
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Heather Hilmoe
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Juliette Hong
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Mark A Ware
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada.,Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| |
Collapse
|
34
|
Darnall BD, Mackey SC, Lorig K, Kao MC, Mardian A, Stieg R, Porter J, DeBruyne K, Murphy J, Perez L, Okvat H, Tian L, Flood P, McGovern M, Colloca L, King H, Van Dorsten B, Pun T, Cheung M. Comparative Effectiveness of Cognitive Behavioral Therapy for Chronic Pain and Chronic Pain Self-Management within the Context of Voluntary Patient-Centered Prescription Opioid Tapering: The EMPOWER Study Protocol. Pain Med 2021; 21:1523-1531. [PMID: 31876947 PMCID: PMC7530567 DOI: 10.1093/pm/pnz285] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Objective. Evidence to date, while sparse, suggests that patients taking long-term opioids require special considerations and protections to prevent potential iatrogenic harms from opioid de-prescribing, such as increased pain or suffering. Following this study protocol, the EMPOWER study seeks to address multiple unmet needs of patients with chronic pain who desire to reduce long-term opioid therapy, and provide the clinical evidence on effective methodology. Methods. EMPOWER applies patient-centered methods for voluntary prescription opioid reduction conducted within a comprehensive, multi-state, 3-arm randomized controlled comparative effectiveness study of three study arms (1) group cognitive behavioral therapy for chronic pain; (2) group chronic pain self-management; and (3) usual care (taper only). Specialized electronic data capture systems collect patient reported symptoms and satisfaction data weekly and monthly during the taper, with real-time clinical alerts and electronic feedback loops informing, documenting, and steering needed care actions. Conclusion. The EMPOWER study seeks to provide granular evidence on patient response to voluntary opioid tapering, and will provide evidence to inform clinical systems changes, clinical care, patient satisfaction, and patient outcomes for opioid reduction.
Collapse
Affiliation(s)
- Beth D Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Sean C Mackey
- Division of Pain Medicine, Stanford Systems Neuroscience and Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kate Lorig
- Stanford University School of Medicine, Palo Alto, California
| | - Ming-Chih Kao
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Aram Mardian
- Department of Family, Community, and Preventive Medicine, Phoenix VA Health Care System, Chronic Pain Wellness Center, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | | | - Joel Porter
- Department of Family Medicine, Intermountain Healthcare, Layton, Utah
| | - Korina DeBruyne
- Division of Primary, Preventive and, Community Care, Stanford School of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Murphy
- James A. Haley Veterans' Hospital, University of South Florida School of Medicine, Tampa, Florida
| | - Luzmercy Perez
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Heather Okvat
- Department of Family, Community, and Preventive Medicine, Phoenix VA Health Care System, Chronic Pain Wellness Center, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Lu Tian
- Stanford University School of Medicine, Palo Alto, California
| | - Pamela Flood
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Mark McGovern
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Luana Colloca
- University of Maryland School of Nursing, University of Maryland School of Medicine, Baltimore, Maryland
| | - Heather King
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | | | | | - Matthias Cheung
- Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, California, USA
| |
Collapse
|
35
|
You DS, Mardian AS, Darnall BD, Chen CYA, De Bruyne K, Flood PD, Kao MC, Karnik AD, McNeely J, Porter JG, Schwartz RP, Stieg RL, Mackey SC. A Brief Screening Tool for Opioid Use Disorder: EMPOWER Study Expert Consensus Protocol. Front Med (Lausanne) 2021; 8:591201. [PMID: 33869240 PMCID: PMC8044786 DOI: 10.3389/fmed.2021.591201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
Growing concerns about the safety of long-term opioid therapy and its uncertain efficacy for non-cancer pain have led to relatively rapid opioid deprescribing in chronic pain patients who have been taking opioid for years. To date, empirically supported processes for safe and effective opioid tapering are lacking. Opioid tapering programs have shown high rates of dropouts and increases in patient distress and suicidal ideation. Therefore, safe strategies for opioid deprescribing that are more likely to succeed are urgently needed. In response to this demand, the EMPOWER study has been launched to examine the effectiveness of behavioral medicine strategies within the context of patient-centered opioid tapering in outpatient settings (https://empower.stanford.edu/). The EMPOWER protocol requires an efficient process for ensuring that collaborative opioid tapering would be offered to the most appropriate patients while identifying patients who should be offered alternate treatment pathways. As a first step, clinicians need a screening tool to identify patients with Opioid Use Disorder (OUD) and to assess for OUD severity. Because such a tool is not available, the study team composed of eight chronic pain and/or addiction experts has extended a validated screening instrument to develop a brief and novel consensus screening tool to identify OUD and assess for OUD severity for treatment stratification. Our screening tool has the potential to assist busy outpatient clinicians to assess OUD among patients receiving long-term opioid therapy for chronic pain.
Collapse
Affiliation(s)
- Dokyoung S You
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Aram S Mardian
- Department of Family, Community and Preventive Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States.,Phoenix VA Health Care System, Phoenix, AZ, United States
| | - Beth D Darnall
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Chwen-Yuen A Chen
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Korina De Bruyne
- Division of Primary, Preventive, and Community Care, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Pamela D Flood
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Ming-Chih Kao
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Anita D Karnik
- Phoenix VA Health Care System, Department of Psychiatry, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States
| | - Jennifer McNeely
- Department of Population Health, Section on Tobacco, Alcohol, and Drug Use, New York University School of Medicine, New York, NY, United States
| | - Joel G Porter
- Intermountain Healthcare, Family Medicine, Layton, UT, United States
| | | | | | - Sean C Mackey
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| |
Collapse
|
36
|
Petrou PA, Leong MS, Mackey SC, Salmasi V. Stanford Pragmatiec Effectiveness Comparison (SPEC) protocol: Comparing long-term effectiveness of high-frequency and burst spinal cord stimulation in real-world application. Contemp Clin Trials 2021; 103:106324. [PMID: 33621631 DOI: 10.1016/j.cct.2021.106324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/17/2021] [Accepted: 02/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES High-frequency and burst stimulation are newer waveforms that have demonstrated promise compared to traditional tonic spinal cord stimulation (SCS), but more studies are needed to compare their effectiveness. We report the study methods for an ongoing, single center, pragmatic randomized clinical trial to compare the effectiveness of high-frequency and burst SCS in patients with chronic back and/or leg pain. MATERIALS AND METHODS Participants who are candidates for spinal cord stimulation are enrolled and screened. Participants will be randomly assigned using point-of-care randomization to receive either high-frequency or burst SCS. Data collection will be through Stanford Pain Management Center's learning healthcare system: CHOIR. CHOIR surveys include National Institutes of Health Patient Reported Outcomes Measurement Information System item banks, a body map, questions about pain intensity, pain catastrophizing scale, and questions about patients' pain experience and healthcare utilization. Participants will complete online surveys at baseline and then 1, 3, 6, 12, 18, 24 and 36 months after their device implant. All participants will use our routine process of trial and implant. Reported adverse events are monitored throughout the study. Our primary outcome is change from baseline in pain intensity at 12 months. RESULTS We hypothesize that high-frequency SCS is more effective than burst SCS in improving pain, physical function and pain interference in participants with chronic low back and/or leg pain. CONCLUSIONS The pragmatic nature of our proposed trial enables us to recruit a larger participant cohort faster and to follow up these participants longer than currently published clinical trials.
Collapse
Affiliation(s)
- Philip Anthony Petrou
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, USA
| | - Michael S Leong
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, USA
| | - Sean C Mackey
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, USA
| | - Vafi Salmasi
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, USA.
| |
Collapse
|
37
|
Hettie G, Nwaneshiudu C, Ziadni MS, Darnall BD, Mackey SC, You DS. Lack of Premeditation Predicts Aberrant Behaviors Related to Prescription Opioids in Patients with Chronic Pain: A Cross-Sectional Study. Subst Use Misuse 2021; 56:1904-1909. [PMID: 34369839 PMCID: PMC8928584 DOI: 10.1080/10826084.2021.1958853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE In light of the opioid epidemic, there is a need to identify factors that predict aberrant opioid behaviors including misuse and abuse. Impulsivity has been extensively studied in addiction literature, but not in the context of opioid misuse. Hence, this study aimed to identify which of the impulsivity facets (negative urgency, positive urgency, sensation seeking, lack of perseverance, and lack of premeditation) would predict current aberrant opioid-related behaviors in patients with chronic pain. METHODS Data were collected through an online survey from patients with chronic pain who visited a tertiary pain clinic. Patients were predominately female (74%), middle aged (M = 55 years), and White/Caucasian (84%). Upon consent, they completed a series of surveys including UPPS-P Impulsive Behavior Scale, the Current Opioid misuse Measure, Pain Catastrophizing Scale, PROMIS-anxiety, depression, and physical function, and a 0-10 numerical pain rating scale. Ordinal regression analyses were conducted to test study hypotheses. RESULTS Contrary to expectations, only lack of premeditation predicted higher odds of aberrant opioid-related behaviors in the past 30 days, after controlling for known covariates, and explained 26% of variance. Interestingly, lack of premeditation together with pain catastrophizing as a covariate explained 56% of the variance in aberrant opioid-related behaviors. DISCUSSION The current study is the first to identify a potential role of lack of premeditation as an impulsivity facet predicting aberrant opioid-related behaviors among patients with chronic pain.
Collapse
Affiliation(s)
- Gabrielle Hettie
- Department Anesthesiology, Perioperative and Pain medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Chinwe Nwaneshiudu
- Department Anesthesiology, Perioperative and Pain medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Maisa S Ziadni
- Department Anesthesiology, Perioperative and Pain medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Beth D Darnall
- Department Anesthesiology, Perioperative and Pain medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sean C Mackey
- Department Anesthesiology, Perioperative and Pain medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Dokyoung S You
- Department Anesthesiology, Perioperative and Pain medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| |
Collapse
|
38
|
Hah JM, Hilmoe H, Schmidt P, McCue R, Trafton J, Clay D, Sharifzadeh Y, Ruchelli G, Hernandez Boussard T, Goodman S, Huddleston J, Maloney WJ, Dirbas FM, Shrager J, Costouros JG, Curtin C, Mackey SC, Carroll I. Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial. J Pain Res 2020; 13:2959-2970. [PMID: 33239904 PMCID: PMC7680674 DOI: 10.2147/jpr.s269370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background Preoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use. Methods In this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18–75 years, undergoing diverse operations underwent preoperative assessments of pain, opioid use, substance use, and psychosocial variables. After surgery, a modified Brief Pain Inventory was administered over the phone daily up to 3 months, weekly up to 6 months, and monthly up to 2 years after surgery. Pain and opioid cessation were defined as the first of 5 consecutive days of 0 out of 10 pain or no opioid use, respectively. Results Overall, 36.1%, 19.8%, and 9.5% of patients continued to report pain, and 9.5%, 2.4%, and 1.7% reported continued opioid use at 3, 6, and 12 months after surgery. Preoperative pain at the future surgical site (every 1-point increase in the Numeric Pain Rating Scale; HR 0.93; 95% CI 0.87–1.00; P=0.034), trait anxiety (every 10-point increase in the Trait Anxiety Inventory; HR 0.79; 95% CI 0.68–0.92; P=0.002), and a history of delayed recovery after injury (HR 0.62; 95% CI 0.40–0.96; P=0.034) were associated with delayed pain cessation. Preoperative opioid use (HR 0.60; 95% CI 0.39–0.92; P=0.020), elevated depressive symptoms (every 5-point increase in the Beck Depression Inventory-II score; HR 0.88; 95% CI 0.80–0.98; P=0.017), and preoperative pain outside of the surgical site (HR 0.94; 95% CI 0.89–1.00; P=0.046) were associated with delayed opioid cessation, while perioperative gabapentin promoted opioid cessation (HR 1.37; 95% CI 1.06–1.77; P=0.016). Conclusion Separate risk factors for prolonged post-surgical pain and opioid use indicate that preoperative risk stratification for each outcome may identify patients needing personalized care to augment universal protocols for perioperative pain management and conservative opioid prescribing to improve long-term outcomes.
Collapse
Affiliation(s)
- Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Heather Hilmoe
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Peter Schmidt
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Rebecca McCue
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Jodie Trafton
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA.,VA Program Evaluation and Resource Center, VHA Office of Mental Health Operations, Palo Alto, CA, USA
| | - Debra Clay
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Yasamin Sharifzadeh
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Gabriela Ruchelli
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Tina Hernandez Boussard
- Department of Medicine, Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Stuart Goodman
- Department of Orthopaedic Surgery and (by Courtesy) Bioengineering, Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - James Huddleston
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | | | - Joseph Shrager
- Division of Thoracic Surgery, Stanford University, Stanford, CA, USA
| | - John G Costouros
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Catherine Curtin
- Division of Hand and Plastic Surgery, Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Ian Carroll
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| |
Collapse
|
39
|
Hah JM, Trafton JA, Narasimhan B, Krishnamurthy P, Hilmoe H, Sharifzadeh Y, Huddleston JI, Amanatullah D, Maloney WJ, Goodman S, Carroll I, Mackey SC. Efficacy of motivational-interviewing and guided opioid tapering support for patients undergoing orthopedic surgery (MI-Opioid Taper): A prospective, assessor-blind, randomized controlled pilot trial. EClinicalMedicine 2020; 28:100596. [PMID: 33294812 PMCID: PMC7700897 DOI: 10.1016/j.eclinm.2020.100596] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Postoperative opioid use can lead to chronic use and misuse. Few studies have examined effective approaches to taper postoperative opioid use while maintaining adequate analgesia. METHODS This randomized, assessor-blinded, pilot trial of postoperative motivational interviewing and guided opioid tapering support (MI-Opioid Taper) added to usual care (UC) enrolled patients undergoing total hip or knee arthroplasty at a single U.S. academic medical center. MI-Opioid Taper involved weekly (to seven weeks) and monthly (to one year) phone calls until patient-reported opioid cessation. Opioid tapering involved 25% weekly dose reductions. The primary feasibility outcome was study completion in the group to which participants were randomized. The primary efficacy outcome, time to baseline opioid use, was the first of five consecutive days of return to baseline preoperative dose. Intention-to-treat analysis with Cox proportional hazards regression was adjusted for operation. ClinicalTrials.gov registration: NCT02070003. FINDINGS From November 26, 2014, to April 27, 2018, 209 patients were screened, and 104 patients were assigned to receive MI-Opioid Taper (49 patients) or UC only (55 patients). Study completion after randomization was similar between groups (96.4%, 53 patients receiving UC, 91.8%, 45 patients receiving MI-Opioid Taper). Patients receiving MI-Opioid Taper had a 62% increase in the rate of return to baseline opioid use after surgery (HR 1.62; 95%CI 1.06-2.46; p = 0•03). No trial-related adverse events occurred. INTERPRETATION In patients undergoing total joint arthroplasty, MI-Opioid Taper is feasible and future research is needed to establish the efficacy of MI-Opioid Taper to promote postoperative opioid cessation. FUNDING National Institute on Drug Abuse.
Collapse
Affiliation(s)
- Jennifer M. Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, 1070 Arastradero Rd., Suite 200, Stanford, CA 94304, United States
- Corresponding author.
| | - Jodie A. Trafton
- Psychiatry and Behavioral Sciences, Stanford University, Director, VA Program Evaluation and Resource Center, VHA Office of Mental Health and Suicide Prevention, Menlo Park, CA, United States
| | - Balasubramanian Narasimhan
- Department of Statistics, Department of Biomedical Data Sciences, Stanford University, Stanford CA, United States
| | - Partha Krishnamurthy
- Department of Marketing and Entrepreneurship, C. T. Bauer College of Business, University of Houston, Houston, Texas, United States
| | - Heather Hilmoe
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, California, United States
| | - Yasamin Sharifzadeh
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, California, United States
| | - James I. Huddleston
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, United States
| | - Derek Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, United States
| | | | - Stuart Goodman
- Department of Orthopaedic Surgery and (by courtesy) Bioengineering, Department of Orthopaedic Surgery, Stanford University, United States
| | - Ian Carroll
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, California, United States
| | - Sean C. Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, United States
| |
Collapse
|
40
|
Gilam G, Horing B, Sivan R, Weinman N, Mackey SC. The Decline in Task Performance After Witnessing Rudeness Is Moderated by Emotional Empathy-A Pilot Study. Front Psychol 2020; 11:1584. [PMID: 32733343 PMCID: PMC7358519 DOI: 10.3389/fpsyg.2020.01584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 06/12/2020] [Indexed: 01/10/2023] Open
Abstract
Rude behaviors engulf societies across the world on a daily basis. Witnessing rudeness toward others increases negative affect and decreases performance in various tasks requiring behavioral and cognitive efforts, such as solving word puzzles or creative and flexible thinking. In this pilot study, we examined whether different levels of emotional empathy that may influence susceptibility to others' distress, moderated the declined performance in several such tasks. The study was conducted online as a naturalistic setting for witnessing movie-clips portraying rudeness. We hypothesized that all participants will demonstrate decreased task performance following a rude compared to a neutral condition, but more so for those higher on emotional empathy. Results confirmed each of these hypotheses in one of two different cognitive tasks. Findings suggest that after witnessing rudeness, those higher on emotional empathy perform worse in cognitive tasks. While requiring replication in a larger sample size, empathic processing seems to be a potential moderator of the effect of rudeness on task performance.
Collapse
Affiliation(s)
- Gadi Gilam
- Systems Neuroscience and Pain Laboratory, Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, School of Medicine, Stanford University, Palo Alto, CA, United States.,School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Bar Horing
- School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ronny Sivan
- School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Noam Weinman
- School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Sean C Mackey
- Systems Neuroscience and Pain Laboratory, Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, School of Medicine, Stanford University, Palo Alto, CA, United States
| |
Collapse
|
41
|
Gilam G, Gross JJ, Wager TD, Keefe FJ, Mackey SC. What Is the Relationship between Pain and Emotion? Bridging Constructs and Communities. Neuron 2020; 107:17-21. [PMID: 32562660 DOI: 10.1016/j.neuron.2020.05.024] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/27/2020] [Accepted: 05/15/2020] [Indexed: 01/06/2023]
Abstract
Although pain is defined as a sensory and emotional experience, it is traditionally researched and clinically treated separately from emotion. Conceptual and mechanistic relationships between these constructs highlight the need for better understanding of their bi-directional influences and the value of bridging the pain and emotion research and clinical communities.
Collapse
Affiliation(s)
- Gadi Gilam
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, MC 5596, Palo Alto, CA 94304, USA.
| | - James J Gross
- Department of Psychology, Stanford University, Stanford, CA 94305, USA
| | - Tor D Wager
- Department of Psychological and Brain Sciences, Dartmouth College, HB 6207, Moore Hall, Hanover, NH 03755, USA
| | - Francis J Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27705, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, MC 5596, Palo Alto, CA 94304, USA
| |
Collapse
|
42
|
Ziadni MS, Chen AL, Winslow T, Mackey SC, Darnall BD. Efficacy and mechanisms of a single-session behavioral medicine class among patients with chronic pain taking prescription opioids: study protocol for a randomized controlled trial. Trials 2020; 21:521. [PMID: 32532346 PMCID: PMC7290153 DOI: 10.1186/s13063-020-04415-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/14/2020] [Indexed: 01/28/2023] Open
Abstract
Background Independent of pain intensity, pain-specific distress is highly predictive of pain treatment needs, including the need for prescription opioids. Given the inherently distressing nature of chronic pain, there is a need to equip individuals with pain education and self-regulatory skills that are shown to improve adaptation and improve their response to medical treatments. Brief, targeted behavioral medicine interventions may efficiently address the key individual factors, improve self-regulation in the context of pain, and reduce the need for opioid therapy. This highlights the critical need for targeted, cost-effective interventions that efficiently address the key psychological factors that can amplify the need for opioids and increased risk for misuse. In this trial, the primary goal is to test the comparative efficacy of a single-session skills-based pain management class to a health education active control group among patients with chronic pain who are taking opioids. Methods/design Our study is a randomized, double-blind clinical trial testing the superiority of our 2-h, single-session skills-based pain management class against a 2-h health education class. We will enroll 136 adult patients with mixed-etiology chronic pain who are taking opioid prescription medication and randomize 1:1 to one of the two treatment arms. We hypothesize superiority for the skills-based pain class for pain control, self-regulation of pain-specific distress, and reduced opioid use measured by daily morphine equivalent. Team researchers masked to treatment assignment will assess outcomes up to 12 months post treatment. Discussion This study aims to test the utility of a single-session, 2-h skills-based pain management class to improve self-regulation of pain and reduce opioid use. Findings from our project have the potential to shift current research and clinical paradigms by testing a brief and scalable intervention that could reduce the need for opioids and prevent misuse effectively, efficiently, and economically. Further, elucidation of the mechanisms of opioid use can facilitate refinement of more targeted future treatments. Trial registration ClinicalTrials.gov, ID: NCT03950791. Registered on 10 May 2019.
Collapse
Affiliation(s)
- Maisa S Ziadni
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA. .,Division of Pain Medicine, Stanford Systems Neuroscience and Pain Laboratory, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, MC 2C2728, Palo Alto, CA, 94304, USA.
| | - Abby L Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| | - Tyler Winslow
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| | - Beth D Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| |
Collapse
|
43
|
Karayannis NV, Baumann I, Sturgeon JA, Melloh M, Mackey SC. The Impact of Social Isolation on Pain Interference: A Longitudinal Study. Ann Behav Med 2020; 53:65-74. [PMID: 29668841 PMCID: PMC6301311 DOI: 10.1093/abm/kay017] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Evidence suggests social interactions play an important role in pain perception. Purpose The aim of this study was to determine whether social isolation (SI) in people with persistent pain determines pain interference (PI) and physical function over time. Methods Patients seeking care at a tertiary pain management referral center were administered the Patient Reported Outcome Measurement Information System (PROMIS®) SI, PI, physical function, depression, and average pain intensity item banks at their initial consultation and subsequent visits as part of their routine clinical care. We used a post hoc simulation of an experiment using propensity score matching (n = 4,950) and carried out a cross-lagged longitudinal analysis (n = 312) of retrospective observational data. Results Cross-lagged longitudinal analysis showed that SI predicted PI at the next time point, above and beyond the effects of pain intensity and covariates, but not vice versa. Conclusions These data support the importance of SI as a factor in pain-related appraisal and coping and demonstrate that a comprehensive assessment of the individuals’ social context can provide a better understanding of the differential trajectories for a person living with pain. Our study provides evidence that the impact of pain is reduced in individuals who perceive a greater sense of inclusion from and engagement with others. This study enhances the understanding of how social factors affect pain and have implications for how the effectiveness of therapeutic interventions may be improved. Therapeutic interventions aimed at increasing social connection hold merit in reducing the impact of pain on engagement with activities.
Collapse
Affiliation(s)
- Nicholas V Karayannis
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, Palo Alto, CA USA.,Rehabilitation Services, Stanford Health Care, Stanford, CA, USA
| | - Isabel Baumann
- Institute for Health Sciences, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - John A Sturgeon
- Department of Anesthesiology and Pain Management, University of Washington, Seattle, Washington, USA
| | - Markus Melloh
- Institute for Health Sciences, Zurich University of Applied Sciences, Winterthur, Switzerland.,Curtin University Medical School, Bentley, Australia.,University of Western Australia Medical School, Perth, Australia
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, Palo Alto, CA USA
| |
Collapse
|
44
|
You DS, Ziadni MS, Gilam G, Darnall BD, Mackey SC. Evaluation of Candidate Items for Severe PTSD Screening for Patients With Chronic Pain: Pilot Data Analysis With the IRT Approach. Pain Pract 2020; 20:262-268. [PMID: 31646748 PMCID: PMC7083588 DOI: 10.1111/papr.12848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 10/03/2019] [Accepted: 10/18/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Post-traumatic stress disorder (PTSD) commonly co-occurs with chronic pain. Although PTSD symptoms are associated with negative health outcomes in patients with chronic pain, PTSD is typically under-detected and under-treated in outpatient pain settings. There is a need for rapid, brief screening tools to identify those at greatest risk for severe PTSD symptoms. To achieve that goal, our aim was to use item response theory (IRT) to identify the most informative PTSD symptoms characterizing severe PTSD in patients with chronic pain. METHODS Fifty-six patients (71% female, 61% White) with mixed etiology chronic pain completed the PTSD Checklist-Civilian Version (PCL-C) as part of their appointment with a pain psychologist at a tertiary outpatient pain clinic. We used an IRT approach to evaluate each item's discriminant (a) and severity (b) parameters. RESULTS Findings revealed that "feeling upset at reminders" (a = 3.67, b = 2.44) and "avoid thinking or talking about it" (a = 3.61, b = 2.17) as being highly discriminant for severe PTSD. CONCLUSIONS We identified 2 candidate items for a brief PTSD screener as they were associated with severe PTSD symptoms. These 2 items may provide clinical utility in outpatient pain treatment settings to identify those suffering from severe PTSD, enabling physicians to refer them to trauma-specific evaluation or therapy. Future research is needed to further validate and confirm these candidate PTSD items in a larger clinic sample. LAY SUMMARY The current study used the IRT approach to identify candidate items for a brief screener for severe PTSD. We examined 17 items of the PCL-C, and identified 2 items that were highly discriminant for severe PTSD. The 2 items were "feeling upset at reminders" and "avoid thinking or talking about it." These 2 items may provide clinical utility, since they may enable physicians to screen and make a referral for further assessment or treatment for PTSD.
Collapse
Affiliation(s)
- Dokyoung S You
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Maisa S Ziadni
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Gadi Gilam
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Beth D Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, U.S.A
| |
Collapse
|
45
|
Gilam G, Sturgeon JA, You DS, Wasan AD, Darnall BD, Mackey SC. Negative Affect-Related Factors Have the Strongest Association with Prescription Opioid Misuse in a Cross-Sectional Cohort of Patients with Chronic Pain. Pain Med 2020; 21:e127-e138. [PMID: 31617916 PMCID: PMC7049262 DOI: 10.1093/pm/pnz249] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Increased opioid prescription to relieve pain among patients with chronic pain is associated with increased risk for misuse, potentially leading to substance use disorders and overdose death. We aimed to characterize the relative importance and identify the most significant of several potential risk factors for the severity of self-reported prescribed opioid misuse behaviors. METHODS A sample of 1,193 patients (mean age ± SD = 50.72 ± 14.97 years, 64.04% female) with various chronic pain conditions completed a multidimensional registry assessing four pain severity measures and 14 physical, mental, and social health status factors using the National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS). A validated PROMIS measure of medication misuse was completed by 692 patients who endorsed currently taking opioid medication. Patients taking opioid medications were compared across all measures with those who do not take opioid medications. Subsequently, a data-driven regression analysis was used to determine which measures best explained variability in severity of misuse. We hypothesized that negative affect-related factors, namely anxiety, anger, and/or depression, would be key predictors of misuse severity due to their crucial role in chronic pain and substance use disorders. RESULTS Patients taking opioid medications had significantly greater impairment across most measures. Above and beyond demographic variables, the only and most significant predictors of prescribed opioid misuse severity were as follows: anxiety (β = 0.15, P = 0.01), anger (β = 0.13, P = 0.02), Pain Intensity-worst (β = 0.09, P = 0.02), and depression (β = 0.13, P = 0.04). CONCLUSIONS Findings suggest that anxiety, anger, and depression are key factors associated with prescribed opioid misuse tendencies in patients with chronic pain and that they are potential targets for therapeutic intervention.
Collapse
Affiliation(s)
- Gadi Gilam
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - John A Sturgeon
- Center for Pain Relief, Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Dokyoung S You
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Ajay D Wasan
- Division of Chronic Pain, Department of Anesthesiology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Beth D Darnall
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| |
Collapse
|
46
|
You DS, Hah JM, Collins S, Ziadni MS, Domingue BW, Cook KF, Mackey SC. Evaluation of the Preliminary Validity of Misuse of Prescription Pain Medication Items from the Patient-Reported Outcomes Measurement Information System (PROMIS)®. Pain Med 2019; 20:1925-1933. [PMID: 30856659 PMCID: PMC6784744 DOI: 10.1093/pm/pnz001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS)® includes an item bank for measuring misuse of prescription pain medication (PROMIS-Rx Misuse). The bank was developed and its validity evaluated in samples of community-dwelling adults and patients in addiction treatment programs. The goal of the current study was to investigate the validity of the item bank among patients with mixed-etiology chronic pain conditions. METHOD A consecutive sample of 288 patients who presented for initial medical evaluations at a tertiary pain clinic completed questionnaires using the open-source Collaborative Health Outcomes Information Registry. Participants were predominantly middle-aged (M [SD] = 51.6 [15.5] years), female (62.2%), and white/non-Hispanic (51.7%). Validity was evaluated by estimating the association between PROMIS-Rx Misuse scores and scores on other measures and testing the ability of scores to distinguish among risk factor subgroups expected to have different levels of prescription pain medicine misuse (known groups analyses). RESULTS Overall, score associations with other measures were as expected and scores effectively distinguished among patients with and without relevant risk factors. CONCLUSION The study results supported the preliminary validity of PROMIS-Rx Misuse item bank scores for the assessment of prescription opioid misuse in patients visiting an outpatient pain clinic.
Collapse
Affiliation(s)
- Dokyoung Sophia You
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer M Hah
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Sophie Collins
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Maisa S Ziadni
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Ben W Domingue
- Stanford University Graduate School of Education, Palo Alto, California
| | - Karon F Cook
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sean C Mackey
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| |
Collapse
|
47
|
Hah J, Mackey SC, Schmidt P, McCue R, Humphreys K, Trafton J, Efron B, Clay D, Sharifzadeh Y, Ruchelli G, Goodman S, Huddleston J, Maloney WJ, Dirbas FM, Shrager J, Costouros JG, Curtin C, Carroll I. Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial. JAMA Surg 2019; 153:303-311. [PMID: 29238824 DOI: 10.1001/jamasurg.2017.4915] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance Guidelines recommend using gabapentin to decrease postoperative pain and opioid use, but significant variation exists in clinical practice. Objective To determine the effect of perioperative gabapentin on remote postoperative time to pain resolution and opioid cessation. Design, Setting, and Participants A randomized, double-blind, placebo-controlled trial of perioperative gabapentin was conducted at a single-center, tertiary referral teaching hospital. A total of 1805 patients aged 18 to 75 years scheduled for surgery (thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, and shoulder arthroscopy) were screened. Participants were enrolled from May 25, 2010, to July 25, 2014, and followed up for 2 years postoperatively. Intention-to-treat analysis was used in evaluation of the findings. Interventions Gabapentin, 1200 mg, preoperatively and 600 mg, 3 times a day postoperatively or active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours. Main Outcomes and Measures Primary outcome was time to pain resolution (5 consecutive reports of 0 of 10 possible levels of average pain at the surgical site on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year. Results Of 1805 patients screened for enrollment, 1383 were excluded, including 926 who did not meet inclusion criteria and 273 who declined to participate. Overall, 8% of patients randomized were lost to follow-up. A total of 202 patients were randomized to active placebo and 208 patients were randomized to gabapentin in the intention-to-treat analysis (mean [SD] age, 56.7 [11.7] years; 256 (62.4%) women and 154 (37.6%) men). Baseline characteristics of the groups were similar. Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in the intention-to-treat analysis. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in the number of adverse events as well as the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]). Conclusions and Relevance Perioperative administration of gabapentin had no effect on postoperative pain resolution, but it had a modest effect on promoting opioid cessation after surgery. The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin in the context of specific operations to decrease opioid use should be addressed in further research. Trial Registration clinicaltrials.gov Identifier: NCT01067144.
Collapse
Affiliation(s)
- Jennifer Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
| | - Peter Schmidt
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Rebecca McCue
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Keith Humphreys
- Center for Healthcare Evaluation, Veterans Health Administration, Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California
| | - Jodie Trafton
- Center for Healthcare Evaluation, Veterans Health Administration, Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California.,Veterans Administration Program Evaluation and Resource Center, Veterans Health Administration Office of Mental Health Operations, Menlo Park, California
| | - Bradley Efron
- Department of Biomedical Data Science, Stanford University, Palo Alto, California
| | - Debra Clay
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Yasamin Sharifzadeh
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Gabriela Ruchelli
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Stuart Goodman
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California.,Department of Bioengineering, Stanford University, Palo Alto, California
| | - James Huddleston
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Frederick M Dirbas
- Department of General Surgery, Stanford University, Palo Alto, California
| | - Joseph Shrager
- Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University, Palo Alto, California
| | - John G Costouros
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Catherine Curtin
- Division of Hand and Plastic Surgery, Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Ian Carroll
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
| |
Collapse
|
48
|
Heirich MS, Sinjary LS, Ziadni MS, Sacks S, Buchanan AS, Mackey SC, Newmark JL. Use of Immersive Learning and Simulation Techniques to Teach and Research Opioid Prescribing Practices. Pain Med 2019; 20:456-463. [PMID: 30215778 DOI: 10.1093/pm/pny171] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Unsafe opioid prescribing practices to treat acute and chronic pain continue to contribute to the opioid overdose crisis in the United States, a growing public health emergency that harms patients and their communities. Poor opioid prescribing practices stem in part from a lack of education and skills training surrounding pain and opioid management. METHODS As part of the Clinical Pain Medicine Fellowship at Stanford University, physicians were given the opportunity to participate in a pilot program to practice opioid management in a live, simulated interaction. Twenty-seven physician trainees participated in the simulation with a live, standardized patient actor. Before beginning the simulation, participants were given a detailed patient history that included the patient's risk for opioid abuse. They were also provided with relevant risk evaluation and mitigation (REM) tools. All simulation interactions were video-recorded and coded by two independent reviewers. A detailed coding scheme was developed before video analysis, and an inter-rater reliability score showed substantial agreement between reviewers. RESULTS Contrary to expectations, many of the observed performances by trainees contained aspects of unsafe opioid prescribing, given the patient history. Many trainees did not discuss their patient's aberrant behaviors related to opioids or the patient's risk for opioid abuse. Marked disparities were also observed between the trainees' active patient interactions and their written progress notes. DISCUSSION This simulation addresses a pressing need to further educate, train, and provide point-of-care tools for providers prescribing opioids. We present our experience and preliminary findings.
Collapse
Affiliation(s)
- Marissa S Heirich
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Systems Neuroscience and Pain Laboratory, Stanford University School of Medicine, Stanford, CA
| | - Lanja S Sinjary
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Systems Neuroscience and Pain Laboratory, Stanford University School of Medicine, Stanford, CA
| | - Maisa S Ziadni
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Systems Neuroscience and Pain Laboratory, Stanford University School of Medicine, Stanford, CA
| | - Sandra Sacks
- Department of Anesthesiology, Ronald Regan UCLA Medical Center, Los Angeles, CA
| | - Alexandra S Buchanan
- Center for Immersive and Simulation-based Learning, Stanford University School of Medicine, Stanford CA
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Systems Neuroscience and Pain Laboratory, Stanford University School of Medicine, Stanford, CA
| | - Jordan L Newmark
- Department of Anesthesiology, Pain and Functional Restoration Clinic, Alameda Health System, Oakland, CA.,Department of Anesthesiology, Perioperative, and Pain Medicine, Addiction, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
49
|
Martucci KT, MacNiven KH, Borg N, Knutson B, Mackey SC. Apparent Effects of Opioid Use on Neural Responses to Reward in Chronic Pain. Sci Rep 2019; 9:9633. [PMID: 31270360 PMCID: PMC6610070 DOI: 10.1038/s41598-019-45961-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 06/17/2019] [Indexed: 11/09/2022] Open
Abstract
Neural responses to incentives are altered in chronic pain and by opioid use. To understand how opioid use modulates the neural response to reward/value in chronic pain, we compared brain functional magnetic resonance imaging (fMRI) responses to a monetary incentive delay (MID) task in patients with fibromyalgia taking opioids (N = 17), patients with fibromyalgia not taking opioids (N = 17), and healthy controls (N = 15). Both groups of patients with fibromyalgia taking and not taking opioids had similar levels of pain, psychological measures, and clinical symptoms. Neural responses in the nucleus accumbens to anticipated reward and non-loss outcomes did not differ from healthy controls in either fibromyalgia group. However, neural responses in the medial prefrontal cortex differed, such that patients with fibromyalgia not taking opioids demonstrated significantly altered responses to anticipated rewards and non-loss outcomes compared to healthy controls, but patients with fibromyalgia taking opioids did not. Despite limitations including the use of additional non-opioid medications by fibromyalgia patients taking opioids, these preliminary findings suggest relatively "normalized" neural responses to monetary incentives in chronic pain patients who take opioids versus those who do not.
Collapse
Affiliation(s)
- Katherine T Martucci
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University School of Medicine, Stanford, California, USA. .,Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Kelly H MacNiven
- Department of Psychology, Symbiotic Project on Affective Neuroscience Laboratory, Stanford University, Stanford, California, USA
| | - Nicholas Borg
- Department of Psychology, Symbiotic Project on Affective Neuroscience Laboratory, Stanford University, Stanford, California, USA
| | - Brian Knutson
- Department of Psychology, Symbiotic Project on Affective Neuroscience Laboratory, Stanford University, Stanford, California, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
50
|
Rosenberg GM, Shearer EJ, Zion SR, Mackey SC, Morris AM, Spain DA, Weiser TG. Implementation Challenges Using a Novel Method for Collecting Patient-Reported Outcomes After Injury. J Surg Res 2019; 241:277-284. [PMID: 31042606 DOI: 10.1016/j.jss.2019.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/02/2018] [Accepted: 04/03/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Monitoring longitudinal patient-reported outcomes after injury is important for comprehensive trauma care. Current methodologies are resource-intensive and struggle to engage patients. MATERIALS AND METHODS Patients ≥18 y old admitted to the trauma service were prospectively enrolled. The following inclusion criteria were used: emergency operation, ICU length of stay ≥2 midnights, or hospital length of stay ≥4 d. Validated and customized questionnaires were administered using a novel internet-based survey platform. Three-month follow-up surveys were administered. Contextual field notes regarding barriers to enrollment/completion of surveys and challenges faced by participants were recorded. RESULTS Forty-seven patients were eligible; 26 of 47 (55%) enrolled and 19 of 26 (73%) completed initial surveys. The final sample included 14 (74%) men and 5 (26%) women. Primary barriers to enrollment included technological constraints and declined participation. Contextual field notes revealed three major issues: competing hospital tasks, problems with technology, and poor engagement. The average survey completion time was 43 ± 27 min-21% found this too long. Seventy-four percent reported the system "easy to use" and 95% reported they would "very likely" or "definitely" respond to future surveys. However, 10 of 26 (38%) patients completed 3-mo follow-up. CONCLUSIONS Despite a well-rated internet-based survey platform, study participation remained challenging. Lack of email access and technological issues decreased enrollment and the busy hospitalization posed barriers to completion. Despite a thoughtful operational design and implementation plan, the trauma population presented a challenging group to engage. Next steps will focus on optimizing engagement, broadening access to survey reminders, and enhancing integration into clinical workflows.
Collapse
Affiliation(s)
- Graeme M Rosenberg
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University, Stanford, California.
| | - Emily J Shearer
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University, Stanford, California
| | - Sean R Zion
- Department of Psychology, Stanford University, Stanford, California
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | - Arden M Morris
- Department of Surgery, Stanford - Surgery Policy Improvement Research & Education Center, Stanford University, Palo Alto, California
| | - David A Spain
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University, Stanford, California
| | - Thomas G Weiser
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University, Stanford, California; Department of Surgery, Stanford - Surgery Policy Improvement Research & Education Center, Stanford University, Palo Alto, California; Department of Clinical Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK
| |
Collapse
|