The journal of pain : official journal of the American Pain Society
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Randomized Controlled Trial
The association between negative affect and prescription opioid misuse in patients with chronic pain: the mediating role of opioid craving.
Over the past decade, considerable research has accumulated showing that chronic pain patients experiencing high levels of negative affect (NA) are at increased risk for prescription opioid misuse. The primary objective of the present study was to examine the factors that underlie the association between NA and prescription opioid misuse among patients with chronic pain. In this study, 82 patients with chronic musculoskeletal pain being prescribed opioid medication completed the Current Opioid Misuse Measure, a well-validated self-report questionnaire designed to assess prescription opioid misuse. Patients were also asked to complete self-report measures of pain intensity, NA, and opioid craving. A bootstrapped multiple mediation analysis was used to examine the mediating role of patients' pain intensity and opioid craving in the association between NA and prescription opioid misuse. Consistent with previous research, we found a significant association between NA and prescription opioid misuse. Interestingly, results revealed that opioid craving, but not pain intensity, mediated the association between NA and opioid misuse. The Discussion addresses the potential psychological and neurobiological factors that might contribute to the interrelationships among NA, opioid craving, and prescription opioid misuse in patients with pain. The clinical implications of our findings are also discussed. ⋯ Our study provides new insights into the factors that underlie the association between negative affect and prescription opioid misuse in patients with chronic pain. Our findings could have important clinical implications, particularly for patients being prescribed opioid medication, and for reducing rates of opioid misuse in patients with pain.
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Assessing if an individual patient has achieved clinically meaningful changes in pain intensity is a core aspect in the evaluation of pain treatments. The aim of the present study was to define minimally clinically significant differences (MCSDs) for the numerical rating scale (0-10 NRS) in adolescents with chronic pain. Data from 153 adolescents who completed an inpatient treatment were analyzed. MCSDs were defined as those cut points that yielded an optimal balance between sensitivity and specificity with regard to patients' global impression of change. The variability of the empirically defined cut points was quantified using bootstrapping. Our results show that raw changes of 1 NRS point and percent changes of 12.5% can be considered MCSDs both within the full sample and within various subsamples of patients. Applying the MCSDs developed for adults to pediatric patients yielded extremely low sensitivities; for example, only 22% of the children who described global improvement met the 50% decrease in pain criterion. Studies evaluating chronic pain treatments for adolescents should use MCSDs that are specifically developed for this group of patients. Raw changes of 1 point and 12.5% on the 0 to 10 NRS should be considered clinically meaningful. On a methodological level, we call for more systematic studies aimed at defining MCSDs that also address the variability of cut point estimates so as to foster the integration of findings. ⋯ Many studies are aimed at empirically defining cut points for clinically relevant pain using receiver operating characteristic-based methods. For the first time, we apply these methods to children and show that even when taking into account the variability of the method, cut points specific for children are needed.
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Chronic pain is influenced by biological, psychological, social, and cultural factors. The current study investigated potential roles for combinations of genetic and psychological factors in the development and/or maintenance of chronic musculoskeletal pain. An exercise-induced shoulder injury model was used, and a priori selected genetic (ADRB2, COMT, OPRM1, AVPR1 A, GCH1, and KCNS1) and psychological (anxiety, depressive symptoms, pain catastrophizing, fear of pain, and kinesiophobia) factors were included as predictors. Pain phenotypes were shoulder pain intensity (5-day average and peak reported on numerical rating scale), upper extremity disability (5-day average and peak reported on the QuickDASH), and shoulder pain duration (in days). After controlling for age, sex, and race, the genetic and psychological predictors were entered as main effects and interaction terms in separate regression models for the different pain phenotypes. Results from the recruited cohort (N = 190) indicated strong statistical evidence for interactions between the COMT diplotype and 1) pain catastrophizing for 5-day average upper extremity disability and 2) depressive symptoms for pain duration. There was moderate statistical evidence for interactions for other shoulder pain phenotypes between additional genes (ADRB2, AVPR1 A, and KCNS1) and depressive symptoms, pain catastrophizing, or kinesiophobia. These findings confirm the importance of the combined predictive ability of COMT with psychological distress and reveal other novel combinations of genetic and psychological factors that may merit additional investigation in other pain cohorts. ⋯ Interactions between genetic and psychological factors were investigated as predictors of different exercise-induced shoulder pain phenotypes. The strongest statistical evidence was for interactions between the COMT diplotype and pain catastrophizing (for upper extremity disability) or depressive symptoms (for pain duration). Other novel genetic and psychological combinations were identified that may merit further investigation.
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Complex regional pain syndrome (CRPS) is a distressing and difficult-to-treat complication of wrist fracture. Estimates of the incidence of CRPS after wrist fracture vary greatly. It is not currently possible to identify who will go on to develop CRPS after wrist fracture. In this prospective cohort study, a nearly consecutive sample of 1,549 patients presenting with wrist fracture to 1 of 3 hospital-based fracture clinics and managed nonsurgically was assessed within 1 week of fracture and followed up 4 months later. Established criteria were used to diagnose CRPS. The incidence of CRPS in the 4 months after wrist fracture was 3.8% (95% confidence interval = 2.9-4.8%). A prediction model based on 4 clinical assessments (pain, reaction time, dysynchiria, and swelling) discriminated well between patients who would and would not subsequently develop CRPS (c index .99). A simple assessment of pain intensity (0-10 numerical rating scale) provided nearly the same level of discrimination (c index .98). One in 26 patients develops CRPS within 4 months of nonsurgically managed wrist fracture. A pain score of ≥5 in the first week after fracture should be considered a "red flag" for CRPS. ⋯ This study shows that excessive baseline pain in the week after wrist fracture greatly elevates the risk of developing CRPS. Clinicians can consider a rating of greater than 5/10 to the question "What is your average pain over the last 2 days?" to be a "red flag" for CRPS.
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Timely intervention and recovery is beneficial to patients with chronic disabling occupational musculoskeletal disorders. Therefore, a surgical option process was developed for use in a functional restoration program (FRP) to allow chronic disabling occupational musculoskeletal disorder patients who were undecided about elective orthopedic surgery to participate in interdisciplinary rehabilitation, rather than suspending treatment, until the surgical option could be resolved. A consecutive cohort of 295 chronic disabling occupational musculoskeletal disorder patients with an unresolved surgical option was admitted to an FRP and their surgical preference at FRP midpoint was determined. The majority of patients declined surgery (n = 164) and were invited to complete the FRP. The remainder elected to pursue surgery and either underwent surgery (n = 43) or had their surgical request denied (n = 38). In the post-FRP year, only .8% of patients reversed their original decision and underwent surgery. Patients whose surgical preferences were accommodated (ie, the declined-surgery/underwent-surgery groups) demonstrated significant psychosocial improvement and excellent socioeconomic outcomes, which were similar to those of FRP patients without a surgical option. Patients whose request for surgery was denied had poorer outcomes than the other groups, but still outperformed FRP dropouts. This suggests that the addition of a formal surgical option process to an interdisciplinary FRP facilitated the surgical decision-making process and helped prevent delayed recovery. ⋯ This study introduces a surgical option process to improve outcomes for patients with chronic disabling occupational musculoskeletal disorders who are undecided about elective orthopedic surgery. The addition of a surgical option process to interdisciplinary rehabilitation may resolve surgical indecision, improve outcomes, promote psychosocial recovery, and facilitate progression to Maximum Medical Improvement.